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S�fen�l��tt 1H�ela�fni<ns 1� Va��Pnae dee&nanaLa®>ln <br />I understand that due to my occupational exposure to Ulood or other potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious. <br />However, I decline Hepatitis.B vaccination at this time. I understand that by declining <br />this 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 wait to be vaccinated with Hepatitis B vaccine, I may do so. <br />Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br />Exposur�e(to Bloodborne Pathogens, Occupational Safety and Health Act. <br />I, w15 U (1 Q(AV `QZ have decided not to receive injections of <br />(PiinC Narady <br />I:�Policy and Legal CHP�liealCki Forms,Crim Bkgrd Chcic, drag screen, fingerprint fm' SCudenCs�IleaIIlr <br />Forms 2011 ?012�Hep B Vaccine Decline Form.doc <br />