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HEPATITIS B VACCINATION <br />DECLINATION FORM <br />Date: Io. 11. 'Z'� <br />Employee Name: %in/DPIE V9nr6WD b5 feckfil i ,JR <br />Employee ID#: <br />I understand that due to my occupational exposure to blood or other potential infectious materials <br />I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the <br />opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I <br />decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine, I <br />continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I continue to <br />have occupational exposure to blood or other potentially infectious materials and I want to be <br />vaccinated with hepatitis B vaccine, I can receive the vaccination series at any time at no charge <br />to me. <br />Ai <br />Employee Signature " <br />1a-1`3.2 <br />Date <br />Facility Representative Signature Date <br />