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I understand thaC due to my occupational exposure to blood or other potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious. <br />However, I declare 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 />btnre; 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 Occupational <br />Exposure to Bloodborne Pathogens- Occupa <br />tional Safety and Health Act. <br />(tcave decided not to receive injections of <br />(Piint Name) <br />I:�Policy and Legal CI3P1I3eald� Farms,Crim Slcgrd Chck, drag screen, fingerprL�c for Smdents�IIea1tU <br />Forms 201I ?012�I3ep R Vaccine Decline Porm.doc <br />