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Facility Name (PRINT) <br />Practitioner Name (PRI <br />Hepatitis B virus (HBV) Declination Statement <br />I understand that due to my occupational exposure to blood or other potentially infectious <br />materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been <br />given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to me; <br />however, I decline hepatitis B vaccination at this time. I understand that by declining this <br />vaccine I continue to be at riskof quirm hepatitis B, a serious disease. If, in the future <br />I continue to have occupational e p sure to blood or other potentially infectious materials <br />and I want to Pe vaccinated wit tis B vaccine, I can receive the vaccination series <br />at no charge t me. <br />OSHA's Moodbo a Pathogens Stand d (29CF 1910.1030 App A) <br />Employee <br />