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�fCurc1Il�YAC1 Z���'tlle�i6 � �T���n�ti � �¢cIlr�t�i;:fi��� <br />I understand that due�to my occupational exposure to blood or other potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (FAV) infectious. <br />However, I decline Hepatitis.B vaccination at this time. I understand that by declining <br />this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. if, in the <br />hLure, 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 />Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />I, ClcwA', <br />u CQQmOna ,have decided nat to receive injections of <br />(Pri it Name) <br />Date <br />I:lPo]icy and Legal CHPIHealtti Forms,Crim Bkgrd Chck, drag screen, fingerprinC for SCudents�FIealfh <br />Forms 2011 ?012�Iiep B Vaccvie Decline Form.doc <br />