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Student hepatitis B- Vaccir-.e Declination <br />I understand that due to my occupational exposure to NOW or other potentially infectious <br />materials I may be at risk of acquiring or Cransmitting Hepatitis B virus (HBV) infections. <br />However, T decline Hepatitis R vaccination at dus tune. 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 T want to be vaccinated with Hepatitis B vaccine, Ianay do so. <br />Reference: Appendix A, 29 Code of hederaJ Regulations 1910.1030 Occupational <br />Exposure to Bloodborne Pathogens. Occupational Safety and IIealth Act. <br />L Q,rri n np _ Tgr rem have decided not to receive injections of <br />(Print Name) <br />Date <br />LCPolicy and Legal CBMIlealth Porms,Crim Dkgrd Click, dntg screen, fingerprint far Stude.ni-Mcalih <br />Porins 20)1.2012\Hel) B Vaccinc Decline Poru).doe <br />