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Facili ID# <br /> I.Program ID# <br /> Hepatitis B Declination Statement <br /> I understand that due to my occupational exposure to blood or other potentially <br /> infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I <br /> have read and understand the health risks involved with Hepatitis B; however, I <br /> voluntarily decline Hepatitis B vaccination at this time. I fully understand the risk of its <br /> transmission and have full knowledge of its effects on the human body. I understand <br /> that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious <br /> disease. <br /> SIGNATURE: DATE: <br /> PRINT NAME: TA131091V C (A'VES <br /> ADDRESS: � CITY: _ STATE CA ZIP 9S <br /> W.SDWIEH-MOGPAMS A PRDACTSMOY ARWOPMSVNORO DOC%HEPAT?IS 8 DEGLM T10N 5TA1 ENT,423 I3.Eo <br />