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IMM�I�epatt tris lb' Vaccine Declination <br /> I understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious. <br /> However, I decline Hepatitis.B vaccination at this time. I understand that by declining <br /> this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the <br /> future, I continue to have occupational exposure to blood or other potentially infectious <br /> materials and I want to be vaccinated with Hepatitis B vaccine, I may do so. <br /> Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br /> Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br /> I, �72orU�YIG. 1"C noN a, have decided not to receive injections of <br /> (Prig Name) <br /> 5 2020 <br /> Date S ignatui e <br /> I:\Policy and Legal CHP\iealth Forms,Crim Blcgrd Chcic,drug screen,fingerprint for Students\Health <br /> Forms 2011.2012\IIep B Vaccine Decline Foim.doc <br />