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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 />SIGNATURE: (-� - DATE: A _ <br />PRINT NAME: 2- D tL—r tw+kof,)A-Q-0� <br />ADDRESS: `L(p p ca-eSTF-o CITY: MpuL7S,v STATE C4- ZIP <br />Toa W M mc1 ST. <br />W'Vata1EH-PROGRAMS & PROJECTSIBODY ARWORMS\WORD DOCSWEPATITIS 8 DECLINATION STATEMENT, 4 23 13.docx <br />