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AN EMPLOYEE • <br />�41 Ilk *• * O . <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 THEEMPLOYEE. <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 HAVE BEEN <br />GIVEN THE OPPORTUNITY TO BE VACCINATED WITH HEPATITIS B VACCINE, AT NO CHARGE TO MYSELF. <br />HOWEVER, I DECLINE HEPATITIS B VACCINATION AT THIS TIME. I UNDERSTAND THAT BY DECLINING THIS <br />VACCINE I CONTINUE TO BE AT RISK OF ACQUIRING HEPATITIS B, A SERIOUS DISEASE. IF IN THE FUTURE I <br />CONTINUE TO HAVE OCCUPATIONAL EXPOSURE TO BLOOD OR OTHER POTENTIALLY INFECTIOUS MATERIALS <br />AND I WANT TO BE VACCINATED WITH HEPATITIS B VACCINE, <br />I CAN RECEIVE THE VACCINATION SERIES AT NO CHARGE TO ME. <br />NAME OF EMPLOYEE (PLEASE PRINT) R40Y0 <br />EMPLOYEEFj �41rr1.i 1 w �. <br />... <br />• EMPLOYEES TO WAIVE LIABILITY IN ORDER TO RECEIVE THE VACCINE. <br />PARTICIPATION IN PRE-SCREENING ASA PREREQUISITE FOR RECEIVING THE VACCINE. <br />