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I understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I may be at risk of acquiring 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 acquiring 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 I want to be vaccinated with Hepatitis B vaccine,I 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, f '�G'1 V ,have decided not to receive injections of <br /> `� (Piint ame) <br /> D ate Signature <br /> I:1Policy and Legal CHP\Healdi Forms,Crim Blcgrd Chcic,drug screen,fingerprint for&udents\Health <br /> Forms 2011.2012�Hep B Vaccine Decline Form.doc <br />