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Declination Statement <br /> I understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I may be at risk of acquiring hepatitis B virus(HBV) infection. I have been <br /> given the opportunity to be vaccinated with hepatitis B vaccine,at no charge to me; <br /> however, I decline hepatitis B vaccination at this time. I understand that by declining this <br /> vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If, in the future <br /> I continue to have occupational exposure to blood or other potentially infectious materials <br /> and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series <br /> at no charge to me. <br /> Employee Signature:, Date: <br /> 1/'T <br />