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w <br /> Hepatitis B Vaccination Declination Statement <br /> (Fed OSHA 1910 . 1030 App A) <br /> I understand that due to my occupational exposure to blood or other potentially infectious materials I <br /> may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be <br /> vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B <br /> vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of <br /> acquiring hepatitis B, a serious disease. If in the fixture I continue to have occupational exposure to <br /> blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I <br /> can receive the vaccination series at no charge to me. <br /> job AN axi\Q <br /> Print Name <br /> / 22 <br /> SInhature Date <br />