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l Utl2b, I1:Vl AM IML1_U4&.d.jpeg <br /> 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. 1 understand <br /> that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious <br /> disease. <br /> SIGNATURE: DATE: S <br /> PRINT NAME: %6e.eLe <br /> ADDRESS: lGo H,��/x� �� CITY: / _et1iral9 STATE ZIP <br /> W.NYNNJR06PA4M1 C PMJFClSNOOYM/1iOI1NSWfM OOCAIICPA11fO II➢CCINATIW16TA1CYEtlf, SJ 1>ya <br /> hHnn•//moil n....r.l..n..m/moil/, /l1/NinFnv/CI,.Iinn�M1.J-.AGmI`iF.J1.1AOiA...1(I VRiAY...7nr.i..nln -l➢.mnnnnnnOn NIA-/11 1/ <br />