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Facility ID# <br /> Program ID # <br /> Hepatitis S 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 /> H, L <br /> � 1 <br /> PRINT NAME : ')VOJI ( , 1°tt c h i (1 , <br /> ADDRESS : .250)i c ��,�1� � ( 1 CITY : STATE ZIP9J V2— <br /> W 1Dala\EH-PROGRAMS & PROJECTSWDY ARTPORMS\WORD DOGS\HEPATITIS 8 DECLINATION STATEMENT, 4 23 13.doa <br />