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,rt<aa�enaf ��e�aa�n><�� � �1�ca:eaae 1J�es;lxlaalioaa <br />i understand that due to my occupational exposure to blood or other potentially infectious <br />materials T may be at risk of acquiring or transmitting Hepatitis B virus (I -MV) infectious. <br />T-Towever, I decline Hepatitis B vaccination at this time. I understand that by declining <br />his vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the <br />future, I continue to [lave 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 Pedet•al Regulations 1910.1(130 Occupational <br />.xpossure to Bloodborne Pathogens. Occupational Safety and ITealth Act. <br />I, V a qtr P h , have decided not to receive injections of <br />(Print Name) <br />I:�Policy and Legal CHP\Health Porms,Crim 131cgrd Chch, drug screen, fingerprint fm• Suideuts�TIealth <br />1"+orms 2011.2012\Ilep R vaccine Decline Porm.dtie <br />