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1 <br /> t • • <br /> Student flepatitis B Vaccine Declination <br /> T understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious. <br /> However, T decline Hepatitis.B vaccination at this time. I understand that by declining <br /> this vaccine., I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the <br /> future, I continue to have occupational exposure to blood or other potentially infectious <br /> materials and T want to be vaccinated with Hepatitis B vaccine, I may do so. <br /> Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br /> Exposure to Bloodborne Pathogens, Occupational Safety and Health Act. <br /> I, have decided not to receive injections of <br /> (Print Nan3e) <br /> Date Signature <br /> IAPolicy and Legal CHI'\Health Forinns,Crirrr Bkgrd Chck,drug screen,fingerprint for Students\Ilealth <br /> taorrns 2011.2012\Hep B Vaccine Decline FornAoc <br />