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Hepatitis B Vaccination Employee <br />Declination (Mandatory) <br />I understand that due to my exposure to blood or other potentially <br />infectious materials, I may be at risk of acquiring a Hepatitis B <br />Virus (HBV) infection. I have been given the opportunity to be <br />vaccinated with Hepatitis B vaccine, at no charge to myself. <br />However, I decline Hepatitis B vaccination at this time. <br />I understand that by declining this vaccine, I continue to be at risk <br />of acquiring Hepatitis B, a serious disease. If in the future I am <br />exposed to blood or other potentially infectious materials and I <br />want to be vaccinated with Hepatitis B vaccine, I can receive the <br />vaccination series at no charge to me. <br />EMPLOYEE'S SIGNATURE <br />PRINT NAME HERE SIGNATURE DATE <br />STORE MANAGER'S SIGNATURE <br />PRINT NAME HERE SIGNATURE DATE <br />Toys "R" Us, Inc. <br />HAZARD COMMUNICATION PROGRAM BLOODBORNE PATHOGENS/ DECLINATION 40 <br />9/1/95 <br />