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�f����ua� �1��3�a�nell5 1� �Ta���lrra� 1��€1lna_It2CLllCtlt& <br />I understand that due'to my occupational exposure to Ulood or oilier potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious. <br />However, I decline Hepatitis.13 vaccination at this time. I understand that by declining <br />this vaccine, 1 continue to be at risk of acquiring Hepatitis B, a serious disease. if, in the <br />uture, I continue to have occupational exposure to blood or other potentially infectious <br />materials and I want to be vaccinated with Hepatitis_B vaccine, I may do so. <br />Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br />Ex(p�osure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />I, 1<lCfi �2�6riV a t wy have decided not to receive injections of <br />(Prior Name) <br />I:�Policy and Legal CHP�Ilealth Portns,Crim $kgrd Chcic, drug screen, fingerprint for SCudents�IleeICU <br />Forms 2011.2012�I1ep H Vaccnie Decline Form.doc <br />