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Student Hepatitis B Vaccine Declination <br /> I understand that due to my occupational expdsure to blood or other potentially infectious <br /> materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious. <br /> However, I 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 I 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 Pathogenps._ Occupational Safety and Health Act. <br /> I, V \ C V A , y\OVA iY 1C have decided not to receive injections of <br /> (Print Name) <br /> Date Signature <br /> I:\Policy and Legal CHP1Health Forms,Crim Bkgrd Click, drug screen, fingerprint for StudentsWcalth <br /> Forms 2011 .2012U-Iep B Vaccine Decline Form.doc <br />