Laserfiche WebLink
i� 0 rer'AS <br />Facility ID# <br />Program ID# PV -05-l803,7 <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: <br />PRINT NAME: <br />ADDRESS: CITY: STATE C.R ZIP �ZOS <br />WADsWEH-PROGRAMS 8 PROJECTS\BODY ARTIFORMS\WORD DOCS\HEPATITIS B DECLINATION STATEMENT. 4 23 13.d— <br />