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SicaT���lrnt 4D�ps2a�nfins � �a��nrra� u��eAa�a�taart <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 (HBV) 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, rf, in the <br />€uture, 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 Regttlations 1910.1Q30 Occupational <br />ExpotsSure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />I, Y�`Q��Uh MCIt�Cay have decided not to receive injections of <br />(Pinrt ame) <br />Date <br />Signahue <br />I:�Folicy and Legal CHP�I3ealfli Porsns,Criin Blcgrd Click, drag screen, fingzrpri��t for Studznts�ITealtU <br />Forms 7_411.2012�IIep B Vaccine Decline Foi:m.doc <br />