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Facility ID# <br />Program ID# <br />Hepatitis B Declination Statement <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 <br />have read and understand the health risks involved with Hepatitis B; however, I <br />voluntarily decline Hepatitis B vaccination at this time. I fully understand the risk of its <br />transmission and have full knowledge of its effects on the human body, I understand <br />that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious <br />disease, <br />SIGNATURE: A A DATE: <br />PRINT NAME: ftrnnAv+du ,Q�,,,e� <br />ADDRESS: lQilS Wes+ Ji1r,SQ� S1 CITY: �j(p�k}oy� STATE C/_1 ZIP �j'Zd3 <br />Wi0alalEHPROCRAMs 8 PaoJECTs1BOOV ARi1FORM51WOR0 OOCSWEPATITIS R DECLINATION STATEMFM.4 2�.13,tlocx <br />