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�>Lai��effi� 1FAep�itnu�� � �sJ��nn� ��c�anatm��i <br />I understand that due to my occupational exposure to blood or other potentially nrfectious <br />materials I may be at risk of acquiring or hansmitting Hepatitis B virus <br />(I3B� infectious. <br />However, I decline Hepatitis B vaccination at this time. T understand that by declining <br />flus vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease, IS, in the <br />fuhue, I continue to have occupational exposure to Ulood 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 />Exposlue to/,,B^loodbojrn�e Pathogens./Occupational Safety and Health Act. <br />I, �-�•""' � I ����L� ,have decided not to receive injections of <br />(Paint Name) —� <br />1:\Pollcy and Legal CHPIIiealdi Pozms,Crim Bk�-d Chck, drug screen, fingerprint for SLudentslIiealtL <br />Forms 2011 ?012u3ep B Vaccine Decline Form.doc <br />