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� i <br />RECEIVED <br />JuN as 2012 <br />LWWRONMENTAL HEALTH <br />PMMIT/SERVICES <br />I understand that due to my occupational exposure to blood or <br />other potentially infectious materials I may be at risk of <br />acquiring hepatitis B virus (HBV) infection. I have been given the <br />opportunity to be vaccinated with hepatitis B vaccine, at no charge <br />to myself. However, I decline hepatitis B vaccination qLt this <br />time. I understand that by declining this vaccine, I continue to <br />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 <br />potentially infectious materials and I want to be vaccinated with <br />hepatitis B vaccine, I can receive the vaccination series at no <br />charge to me. -% <br />9 <br />