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Stan demi -aepa808l3 Vaccine C71ecdi nation <br /> I under;sland thal clue to my occupational exposure to blood or other potentially infectious <br /> malerials I nmy be at risk of acquiring or transmitting Hepalitis B virus (IIRV) infectious . <br /> however, I decline Hepatitis 11 vaccination al this time. I understand that by declining <br /> this vaccine, I continue to be it risk of acquiring I'lepalilis R , a ,serious disease. If, in the <br /> future, I conlinuc to have occupational exposure to blood nr other potentially infecl.ious <br /> materials and I want to be vaccinated with Hepalitis B vaccine, I may do so, <br /> Reference; Appendix A, 29 Code of Federal Regulations 1910. 1030 Occ:upidional <br /> Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br /> I, AC( SSIt o Y t e Q have decided not to receive injections of <br /> (Pciut Name) <br /> 14 <br /> Date Signe <br /> 19Policy and Legal CHP\Health Pocros,Crim nkgrd Click, drug screen, fingc:rprintftn' SladeulsVIfcalth <br /> Kornis 2011 .2012\lief? g Vaccine recline Ponn.dae. <br />