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HEPATITIS B <br /> DECLINATION FORM <br /> Appendix A to Section 191€I.1030—Hepatitis S Vaccine Declination <br /> I understand that due to my occupational exposure to blood or other <br /> potentially infectious materials, I may be at risk of acquiring Hepatitis <br /> 13 Virus (t-If3V) Infection, I have been given the opportunity to be <br /> vaccinated with Hepatitis 0 vaccine, at no charge to myself, <br /> However, I decline the Hepatitis S vaccination at this time, i <br /> understand that by declining this vaccine, I continue to be at risk of <br /> acquiring Hepatitis 13, a serious disease, If in the future I continue to <br /> have occupational exposure to blood or other potentially infectious <br /> materials and I want to be vaccinated with Hepatitis f3 vaccine, I can <br /> receive the vaccination series at no charge to me. <br /> Artist Signature 1- v <br /> Date 22 <br />