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i <br /> Student Hepatitis B Vaccine Declination <br /> I understand that clue to my occupational exposure to blood or other potentially infectious <br /> materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infections. <br /> However, I decline hepatitis B vaccination at this time. 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 may do so. <br /> i <br /> Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br /> Bxpogqs��ure''too,Bloodborne Pathogens. Occupational Safety and Health Act. d <br /> have decided not to receive injections of <br /> (Print Name) -- <br /> i' <br /> 6 <br /> 5 3I Za2zf <br /> Date Signature q <br /> 9 <br /> f <br /> I <br /> I: <br /> 4 <br /> 1 <br /> 1 <br /> lAPolicy and Legal CH[Mcalth,Forms,Crim Bkgrd Click,drug screen,fingerprint for Studenls\Rcalth <br /> Forms 2011.2012\Hep B Vaccine Decline Fonn.doc <br />