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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 />tIowever, 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 occ-upational exposure to blood or other potentially infectious <br />materials and I want to be vaccinated with Hepatitis B vaccine, I.anay do so. <br />.Reference; Appendix A, 29 Code of Federal Regulations 1910.1030 Occupatioiial <br />13.posure to'Bloodborne Pathogens. Occupational Safety and Health Act. <br />I,. �G�T t -L C�''>'p , have decided. not to receive injectiotis of <br />(Print Name) <br />1APolicy and Legal CHP\Healtli Forim,Cdpi Bkgrd (Nick, drupe screen, fingerpdpt for StudentA-lealth <br />l onns 201.1.2012\1-lep .B Vaedhe D.eelirie Fo.an.doc <br />