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I understand that due to.my occupational exposure to blood of 0Lhe1'poleutially inf etiotIs <br /> materials I may be at risk of accluhizg or transmitting Hepatitis B virus (HBV)infectious. <br /> However,I decline Hepatitis B vaccination at t his time. I understand that by declining- <br /> this <br /> ecliningthis 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 1.910.1030 Occupational <br /> Exposure to Bloodborne Pathogens. Occupational Safety and Health Act, <br /> I, Lir , have decided not to receive injections of <br /> {Priv Tame} <br /> Dale S i guglWe <br /> IAPolicy and Legal CHP\Health T`orms,Crim M-M Click,drug screen,fingerprint for StudentsUltalth <br /> Forms 20,11.2012\14ep R Vaccinc Decline Formxloc <br />