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�4tt�enzf I�e�ad��fis E3 Va�esa-ae ��zcla�aa4#®x� <br />I understand that due to my occupational exposure to Ulood or other potentially infections <br />materials I may be at risk of acgnning or transmitting Hepatitis B virus (I -MV) infectious. <br />However, I decline Hepatitis.B vaccination at flus 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 want to be. vaccinated with Hepatitis B vaccine, I may do so. <br />Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occnpatirnral <br />Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />I, a �w nd t! 7j t0 cucx nd.z!�. , have decided not to receive injections of <br />(Print Name) <br />I:�Policy and Legal CHP\Health Fonns,Crim Bk6Rd Chck, drag screen, fingerprint for Students&Iealth <br />Ponns 2011.2012Viep B Vaccine Decline Fonndoc <br />