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StuedentBfepaflTErg - Vaca r, e3 <br /> DecHto ectr <br /> I understand that due to my occupational exposure to blood of other potentially infectious <br /> materials I may be at risk of acquitiug or transmitting Hepatitis B virus (HBV) infectious . <br /> However, I decline Hepatitis 13 vaceination at this tine. I gnderstand 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 i want to be vaccinated with 1lepatitis B vaccine, I may do so. <br /> Reference; Appendix A, 29 Code of federal Regulations 1910. 1030 Occupational <br /> Lxp11 ossure to Bloodborne Pathogens. Occupational Safety and Health Act. <br /> I; kSY iSi'4n T rt4K o-n— 6rat&A have decided not to receive injections of <br /> (Print Name) <br /> DD i.,nawre <br /> - - <br /> 5 <br /> i <br /> IMolicy and Legal CHPAealth Porms,Crim Bkgrd Clrck, drag screen, fingerprinL for StudentsUfcaltli <br /> Forms 21111 2012\Hep R Vaccine Decline Form.doe <br />