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M <br /> Student Hepatitis B Vacefivic Dechn-ation <br /> 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 (14BV) infectious. <br /> However, I decline Hepatitis B vaccination at this tine. 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 occupational exposure to blood or other potentially infectious <br /> materials and I want to be vaccinated with Hepatitis B vaccine, I Illay do so. <br /> Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br /> FAposure to Bloodhorne Pathogens. Occupational Safety and Health Act. <br /> L -AV%tj1TX-,Y p64 have decided not to receive injections of <br /> (Print Name) <br /> Date <br /> (APolicy and Legal CHI'Vicalai Furms,Crim 11kgrd Click,drug screeii,fulgerpring for StudentsWcalth <br /> Forms 2011.2012414ep 8 Vaccine Deelille 1,,ol <br />