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i <br /> 4 <br /> Sinden[ Flepatiiis B Vaccine Declination <br /> I uadersLmd that due to illy occupational exposure to Mood a' other potentially inlbclious <br /> materials I may be at risk of acquiring or Liansmitlin, Flepatilis B virus (I IBV ) infcclious. <br /> I lowever, i decline Hepatitis B vaccination at this time. I understand that by declining <br /> this vaccine, I continue to beat risk of acquiring I lepatilis A, a serious disease. If, io the <br /> future, I continue to have occupational exposure to blood of other potentially infectious <br /> materials and I want to be vaccinated with Hepatitis B vaccine, f may do sn. <br /> Reference: Appendix A , 29 Code of Federal Regulations 1910. 1030 Occupational <br /> Fxpusure to Bloodborne Pathogens. Occopational Safety mad Health Act . <br /> 15kSOJeAA have decided not to receive injections of <br /> Ie - <br /> Dale ignannc <br /> C\Policy mad legal CHNIcallh Pnnns,Crim Bkgul Click, drug sercmi, fingerprint fm Sludentskldental, <br /> Penns 1011 .2012\Hep H Vaccine necliue Poorulor <br />