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i <br /> Hepatitis B DDeclination Statement` <br /> Deolinatio i Statement <br /> 1 understan J that due to my occupational exposure to blood or other potentially infectious materials I <br /> may be at r sk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be <br /> vaccinated ith hepatitis B vaccine, at no charge to me; however, I decline hepatitis B vaccination at <br /> this time. I i inderstand that by declining his vaccine I continue to be at risk of acquiring hepatitis B, a <br /> serious disease, If, in the future I corl a to have occupational exposure to blood or other <br /> potentially ifectious materials and I wart to be vaccinated with hepatitis B vaccine, I can receive the <br /> vaccination series at no charge to me. <br /> Name Printlf d: MQr 1 <br /> Signature: Date: 2L <br /> I <br />