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HEPATITIS B <br />DECLINATION FORM <br />Appendix A to Section 191001030 — Hepatitis B Vaccine Declination <br />1 understand that due to my occupational exposure to blood ar other <br />potentially, Infectious materials, I may be at risk of acquiring Hepatitis <br />8 Virus (1 -IBV) Infection, I have been given the opportunity to be <br />vaceinated with Hepatitis B vaccine, at no charge 10 myself. <br />However, I decline the Hepatitis B vaccination at this time. I <br />understand that by declining this vaccine, I continue to be at risk of <br />acquiring Hepatitis B, a serious disease. It in the future I continue to <br />have occupational exposure to blood or other potentially infectious <br />materials and I want to be vaccinated with Hepatitis B vaccine, I can <br />receive the vaccination series a1 no charge to me <br />Artist Signature r _ <br />We 13'o2Lol <br />