Laserfiche WebLink
V <br /> 7,J-,Ct.,lU-C. <br /> I understand that due to my occupational exposure to blood or other potentially infections <br /> inateials I may be. at risk of acquiring or transmitting Hepatitis B virus (HBV)infectious. <br /> T-Towever, I decline Hepatitis B vaccination at this time. I understand that by declining <br /> this vaccine. I continue to be at risk of acquiring I-Tepatitis B, a serious disease. If, in the <br /> future;I continue to hawe occupational t.xposure. to blood or other-potentially illectious <br /> materials and I want to Lie vaccinated with Hepatitis B vaccine, I.may do so. <br /> Reference: Appendix A,29 Code of Federal Regulations 1.910.1030 Occupational <br /> IlxpostuM to Bloodborne Pathogens, Occupational Safety and 1-lealth Act. <br /> have decided not to receive injections of <br /> (Print Name) <br /> 'b Ci <br /> Date, Sit?natt -e <br /> P\Policy and Legal Clit'\Healtla Fcx-ms,Crim T31�grd Clack,drug sereen,fingeprint for Students}.11ealth <br /> loans 20,11?0l2\14ep B Vacciaie Decline T"+orna.c)oc <br />