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Hepatitis B Vaccine Declination Form <br />The following statement of declination of the hepatitis B vaccine must be signed by <br />an employee who: <br />• Chooses not to accept the vaccine. <br />• Has had appropriate training regarding hepatitis B, hepatitis B vaccination, <br />the efficacy, safety, method of administration and benefits of vaccination, <br />given free of charge to the 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. I <br />have been given the opportunity to be vaccinated with hepatitis B vaccine, at no <br />charge to myself. However, I decline hepatitis B vaccination at this time. I <br />understand that by declining this vaccine I continue to be at risk of acquiring <br />hepatitis B, a serious <br />d' t future I Antinue to have occupational <br />"o <br />er p n 'ally <br />exposure to blood or Misfectiou$ tnaterials and I want to be <br />vaccinated with hepa is B v c �in , I c n recei*A the vaccination series at no charge <br />to me. . if <br />Lim= <br />