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APPENDIX C: Hepatitis B Vaccine Declination <br /> - -Life Line Screening <br /> Hepatitis B Vaccine Declination <br /> Completion of this form is mandatory for all employees who decline to receive the <br /> Hepatitis V vaccination after an exposure incident. <br /> fully 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. <br /> I have been provided with the opportunity to be vaccinated with the Hepatitis B vaccine at <br /> no charge to myself. However, I decline the Hepatitis B vaccination at this time. <br /> I fully understand that, by declining this vaccine, I continue to be at risk of acquiring <br /> Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to <br /> blood or other potentially infectious materials and I want to be vaccinated with Hepatitis V <br /> vaccine, I can receive the vaccination series at no charge to me. <br /> Are you declining because you do not wish to receive the Hepatitis B Vaccine at this time? <br /> Yes No <br /> Are you declining because you have already received the Hepatitis B Vaccine? <br /> Yes No <br /> Employee Name: Employee Signature: Date: <br /> Employee SSN# <br /> Witness Name: Witness Signature: Date: <br /> I1 <br />