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ImmunizationOl 0 <br />Declination <br />I understand that my occupational exposure to patients, blood or other <br />potentially infectious materials at healthcare facilities with the following vaccine <br />preventable diseases puts me at risk of acquiring the disease. I have had the <br />opportunity to be vaccinated, however, I choose to decline the vaccination(s) <br />checked below at this time. 1 understand that by declining vaccine protection I <br />continue to be at risk of acquiring the disease. <br />dHepatitis B <br />Reason for Declination: 10 XY'fl� SS, <br />'` Yl CC0.) S 0.`r W r YvO W <br />[Tetanus/Pertussis/Tdap <br />Reason for Declination: <br />�IP� IYco�- <br />I understand that in the event of exposure, I may be requested to not visit <br />healthcare facilities for at least the incubation period of the disease to which I <br />have been exposed. <br />I acknowledge that each healthcare facility determines vaccination requirements, <br />and that a vaccination declination may not satisfy these requirements. <br />signature: �' Date: v �2 <br />Printed Name: V �1� ► "DY r<'Z'� <br />Company: _ XV 'Visy.-, ,m '�. 01 d <br />