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HEPATITIS B <br /> NOTICE TO EMPLOYEES <br /> DELTAI have been advised of the Agency's policy regarding immunization against Hepatitis B for <br /> HEALTH non-immune employees whose job puts them at risk for this disease. Since my position does <br /> not require me to come into contact with potentially infected persons or materials, I have <br /> elected not to receive this immunization, and do hereby absolve the Agency from any <br /> Providing Health Oriented <br /> servi <br /> tocthe Communityion responsibility or liability should I contract Hepatitis B as a result in any way of my <br /> employment. I further understand that should I decide to become immunized for Hepatitis <br /> B in the future, I will be financially responsible for the procedure. Employees/volunteers <br /> who choose not to accept the vaccine must sign a refusal form. Said individual may change <br /> their mind at a later date, however, they must notify their immediate supervisor, in writing, <br /> to request the vaccine. <br /> Signed: Date: <br /> Witnessed: Date: <br /> 914 N.Center Street <br /> Stockton,CA <br /> 95202 <br /> 209/466-3245 <br /> 0*00 <br /> 911 Industrial Way <br /> Lodi,CA <br /> 95240 <br /> 209/369-2704 <br /> HEPB.ADV <br /> REVISED 01/96 <br /> 011).- <br /> United Way <br /> of Sm Joaq-comfy <br />