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1 understand that due,to my occupational exposure Co Ulood or other potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (I -IBV) 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 />future, I continue to have occupational exposure to blood or other potentially infectious <br />materials and I want to be vaccinated with Hepatitis B vaccine, 1 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, <br />[EI AK; Swtj II&have decided not to receive injections of <br />(Pratt Name) <br />2o2Z <br />Signatuue <br />I:1Folicy and Legal CHP�I3ealtlt Portns,Crim Blcgrd Chck, drug screen, fingerprint for Studuits�i3ealfh <br />Fgnns 2011 ?0121Hep B Vaccine Decline Porm.doc <br />