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Student Hepatitis B Vaccine 1Decli nation <br /> 1 understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I may be at risk of acgnurmg 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 acqumng Hepatitis B , a serious disease. If, in the <br /> future, I continue to have occupational exposure to blood or other potentially infectious <br /> materials and 1 want to be vaccinated with Hepatitis B vaccine, l 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 N hun j 'D i�NN 1��_ have decided not to receive injections of <br /> (hint Name) <br /> Date SignaturdU <br /> I:Tolicy and Legal CIIMealth Fonns,Crirn Bkgrd Chck, drug screen, fingerprint for StudentAl-lealth <br /> Forms 20112012U-Iep B Vaccine Decline Form.doc <br />