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St ,deR,i� {depa$1ell5 3 Udec—i?ae D eeIh7 aItioii. <br /> I understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I n ay be at risk of acquiring or transmitting Hepatitis B-virus (HBV)infectious. <br /> However,I decline Hepatitis B vaccination,at this tune. 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 exposureto bloodor 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, Iaave decided not to receive injections of <br /> i <br /> (Print Nanie) <br /> Date Signature I <br /> I <br /> t <br /> i <br /> I:1Policy and Legal CHP\Heallli Forms,Crim Bkgrd Cbe ,drug screen,fingerprint for Students-leslth <br /> Forins 2011.2012\Hep B Vaccine Decline Form.doe <br />