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Facility ID# <br />Program ID# <br />Hepatitis B Declination Statement <br />I understand that due to my occupational exposure to blood or other potentially <br />infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I <br />have read and understand the health risks involved with Hepatitis B; however, I <br />voluntarily decline Hepatitis B vaccination at this time. I fully understand the risk of its <br />transmission and have full knowledge of its effects on the human body. I understand <br />that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious <br />disease. <br />e ni <br />i�:7��r�►raul� <br />(>'I <br />ADDRESS: � N 2 S u0 (IM A �- <br />CITY: MO�g�-G STATE C/� zIP �S35 / <br />W:IDala1EH-PROGMMS d PROJECTS\ROOT gRTIPORMR\WORD OOCRIHEPPTRIS D OECLINgT10N RigTEMEM, 9 RJ 1S.dou <br />