Laserfiche WebLink
Facility ID# <br />Program ID# <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: '3 12- 412; <br />PRINT NAME: <br />ADDRESS: CITY: STATE ZIP <br />W:1Data1EH-PROGRAMS & PROJECTSWODY ARTFORMSWORD DOCSIHEPATITIS 13 DECLINATION STATEMENT. 4 23 13.d.m <br />