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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 />-f_ <br />SIGNATURE: y� DATE:���,,�� <br />PRINT NAME: �l /�G'rr/GrGi✓ <br />ADDRESS: AW�� OrV CITY: S' - STATE ZIP c <br />W:\DaWEH-PROGRAMS & PROJECTS\BODY ART\FORMS\WORD DOCS\HEPATITIS 13 DECLINATION STATEMENT, 4 23 13.dDm <br />