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. . ` <br /> Hepatitis 8$ Vaccine Declination Form <br /> The following statement of declination of the hepatitis B vaccine must be signed by <br /> anemployee who: <br /> ° <br /> Chooses not toaccept the vaccine. <br /> ° Has had appropriate training regarding hepatitis B, hepatitis Bvaccinetion, <br /> the efficacy, safety, method of administration and benefits of vaccination, <br /> given free ofcharge tmthe employee. <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. l <br /> have been given the opportunity to be vaccinated with hepatitis B vaccine, at no <br /> change to myself. However, l decline hepatitis B vaccination atthis time. I <br /> understand that by declining this vaccine I continue to be at risk of acquiring <br /> hepatitis B, a serious disease. If in the future I continue to have occupational <br /> exposure to blood or other potentially infectious materials and I want to be <br /> vaccinated with hepatitis Bxacc|ne, I can receive the vaccination series at no change <br /> to me. <br /> Employee Signatu Date: Jukdv' <br />