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HEPATITIS B <br />CIECLINATION FORM <br />l understand that due to my occupationat exposure to blood ar other <br />polentially infectious materials, I may be at risk of acquiring Hepatitis <br />Virus (I ABV) Infection, I have been given the opportunity to be <br />vaccinated with Hepatitis 0 vaccine, at no charge to myself, <br />However, I decline the Hepatitis B vaccination at this time, i <br />understand that by declining this vaccina, I continue to be at risk of <br />acquiring Hepatitis B, a serious disease. If in the future I continue to <br />have occupational exposure to blood or other potentially infectious <br />materials and I want to be vaccinated with Hepatitis B vaccine, I can <br />receive the vaccination series at no charge to me. <br />Artist Signature -r <br />pate (a 22 <br />