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�EE��l� �r�e�7��$io5 T �a��jre �Jlecdii�,.�l;l'al'h <br />I tmdersCend diet due to my bceupatiohal exposure to blood or other potentially icil'eetious <br />materials I may be at risk of aeglInIng or transmitting Hepatitis B virus (I -MV) infectious. <br />However, i decline ITepatitis B vaccination at this time. I understand that by declining <br />this vaccine, I continue to be at risk of acquiring Hepatitis % a serious disease. If in the <br />fWore; I continue to have occupational exposure to blood or other potentially infectious <br />materials and T want to be vaccinated with Hepatitis B vaccine, Imay do so. <br />Reference: Appendix !y, 29 Cotle ofi'ederal Reguiatioais 191O.1Q30 Occupational <br />Exposure topBloodborne Pathogens. ''Uccupational Safety and Heald) Art. <br />L KAm�x Ia e� katr� �A� ahW e i have decided not to receive injections of <br />(Priv Name) <br />Ob-Ot(-;Zi <br />I;\Policy and Legnl CHP\Healtli Porms,Crim 13kgrd Click rhvg screen, fingerprinL2m'Students4llen1tU <br />Forinr201 i .2012\Hep }3 Vxccinc Decline Foxm.daC <br />