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Declination Statement <br /> I understand that due to my occupational exposure to blood or other <br /> potentially infectious materials I may be at risk of acquiring hepatitis <br /> B virus (HBV) infection. I have been given the opportunity to be <br /> vaccinated with hepatitis B vaccine, at no charge to me; however, I <br /> decline hepatitis B vaccination at this time. I understand that by <br /> declining this vaccine I continue to be at risk of acquiring hepatitis B,, <br /> a serious disease. If, in the future I continue to have occupational <br /> exposure to blood or other potentially infectious materials and I want <br /> to be vaccinated with hepatitis B vaccine, I can receive the <br /> vaccination series at no charge to me. <br /> Employee Sicnatur � <br /> Dater <br /> �> <br />