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0 <br /> Hepatitis B 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. <br /> I 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 <br /> of its transmission and have full knowledge of its effects on the human body. I <br /> understand that by declining this vaccine I continue to be at risk of acquiring <br /> Hepatitis B, a serious disease. <br /> Signature: C__74 Date: I <br /> Printed Name: Ify-ejo 5C1(C)I'VCVV" <br /> Address: g,STD -qtvjN(yv of- City/Statel_r4cv, . C41- <br /> SAMPLE FORM <br />