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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 rother 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 /> SIGNATURE : N DATE: 7 / 13 / Z Z <br /> PRINT NAME : Fj , y el VIA <br /> ADDRESS : ( N 2S 46 w\ Av-0CITY: G STATE CA ZIP <br /> MOsIa1E11-PROGRAMS d PROJECTS\BODY ARTIPORMS%WCRD OOCSIHEPRTRIS B DECLINATION STATEMENT, 4 23 13.&= <br />