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��;a���r�L�tt i'i���4rnt�� � ����¶ra� ���1_l>>trn�t���� <br />I understand that due,to lnny occupational exposure to blood or other potentially infectious <br />materials I may be at risk of acgltiring oz transnnitting Hepatitis B virus (III3V) infectious. <br />However, I decline Hepatitis B vaccination at this time. T ttnclerstand that by declining <br />this vaccine, I continue to be at risl� of acquiring Hepatitis B, a serious disease. Ii', in ilne <br />ftitilre, T continue to have occupational exposure to blood or other potentially infectious <br />nnatezzals 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, �� ien.e v�•ll,e u <br />ii�it Name) <br />� 2� 22 <br />" Date <br />have decided not to receive injections of <br />Signature <br />I:�l'olicy and Legal C�IF�I3ealt1l Forms,Crim Blcgrd Click, drug screen, fingerpru7t for Students�l-lealth <br />Forms 201I.2012�Hep B Vaccitne Decline Forni.doc <br />' <br />� •i <br />.� <br />� 2� 22 <br />" Date <br />have decided not to receive injections of <br />Signature <br />I:�l'olicy and Legal C�IF�I3ealt1l Forms,Crim Blcgrd Click, drug screen, fingerpru7t for Students�l-lealth <br />Forms 201I.2012�Hep B Vaccitne Decline Forni.doc <br />