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I understand that due,to n1y occupational exposure to blood or other potentially infectious <br />materials I may be at risk of acquhing 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, If, in the <br />future, 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 Regulations 1910.1030 Occupational <br />Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />i <br />have decided not to receive injections of <br />(Pzla <br />t Name) <br />2�- 2v2 2 <br />Date <br />I:�Policy and Legal CHP�T3ealtl� Forms,Crim Bltgrd Chclt, drug screen, fingerprint for Students�Ilealtl� <br />Forms 2011.2012�I-iep B Vaccuie Decline Foruz.doc <br />