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HEPATITIS Es <br />DECLINATION FORM <br />Appendix A ko Section 1910.1630 — Hepakikls 13 Vaccine Declination <br />I understand that due to my occupational exposure to blood or other <br />potentially infectious materials, I may be at risk of acquiring Hepatitis <br />B Virus (1 -IBV) infection. I have been given the opportunity to be <br />vaccinated with Hepatitis B vaccine, at no charge to myself. <br />However, I decline the Hepatitis B vaccination at this time. I <br />understand that by declining this vaccine, I continue to be at risk of <br />acquiring Hepatitis B, a serious disease. If in the future I continue to <br />have occupational exposure to blood or other potentially infectious <br />materials and I want to be vaccinated with Hepatitis B vaccine, I can <br />receive the vaccination series at no charge to me. <br />Artist Signature �-'f'� <br />Date 03/28/2021 <br />