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-PVO 5ti0q 94. <br />Staden t >Hepa t, fis B Vaccine De;vini to-tion <br />I 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 (I-IBV) infectious. <br />�fowever, I decline Hepatitis,B vaccination at dii.s 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 I want to be vaccinated with I3epatitis B vaccine, I may do so. <br />References Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br />Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />have decided not to receive injections of <br />(Print Vame) <br />IS /� Z Z - - <br />D to Sigma h -e <br />a <br />r <br />I.-Tolicy and Legal CHl'1Healih rorms,Crim -Bl grd Chelc, drug screen, fingerprint fol- StudentsU-Tcalth <br />Morins 201.1.20.19-Tep B Vaccine D.eclirie Fonmdoc j <br />i <br />