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m PACIFIC <br />HEPATITIS (B) VACCINATION PROGRAM <br />Acceptance Option: <br />❑ I wish to be provided the opportunity to undergo the Hepatitis B vaccination <br />protocol. <br />Declination Option # 1: <br />❑ I understand that due to my occupational exposure to blood or other potentially <br />infection materials (OPIM), I may be at risk of acquiring Hepatitis B virus (HBV) <br />infection. I have been given the opportunity to be vaccinated with Hepatitis B <br />vaccine, at no charge to me. My employer has advised that OSHA regulations <br />recommend that all dental personnel having patient contact should receive the <br />Hepatitis B vaccination. <br />However, I decline Hepatitis B vaccination at this time. I understand that by <br />declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious <br />disease. If in the future I continue to occupational exposure to blood or OPIM <br />and I want to be vaccinated with Hepatitis B vaccine, I need to notify my <br />supervisor, or a member of my Safety Committee, so that I can receive the <br />vaccination series at no charge to me. <br />Declination Option # 2: <br />ecline to undergo the Hepatitis B vaccination as I have had it in the past. <br />,()//A�h� <br />Date <br />Print Name <br />Signature <br />