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F <br />Student i%` epaffinis B VaICtChI e DeeMnatr io <br />i understand that due,to my occupational exposure to blood or other potentially infectious <br />materials I may be at risk of acquiring 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 serous 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, Ou'a--c�V � �: , have decided not to receive injections of <br />(Print Name) <br />-1- (� - �-O �--3 <br />Date <br />Signature <br />IAPolicy and Legal CHPU-1calth Forms,Crim Bkgrd Chek, & uo screen, fingerprint for StudentsTealth <br />Forms 2011.2012\I3ep B Vaccine Decline Foru.doc <br />