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I understand that due to my occupational exposure to Ulood or other potentially infectious <br />materials I maybe 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 />fut re, I continue to Have occupational exposure to blood or other potentially infectious <br />materials and I want to be vaccinated with Hepatitis B vaccine, 1 may do so. <br />Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupafional <br />Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />I, "u�ia,�, VJ ZEDS have decided not to receive injections of <br />(Print Name) <br />Date <br />Signatm'e <br />I:�Policy and Legal CHP�IIea1tU Forms,Crim Blcgrd Chck, drag screen, fingerpruit for ScudentsllIeallh <br />Forms 2011.2012�I3ep B Vaccine Decline Forni.doc <br />