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�tias��nx� Hel��t��2s J3 \1����Iate>!�ec�aa��ll®�r <br />I understand that ine to my bccupafional exposure to blood or other potentially infeeiions <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious. <br />IIowever, 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 />fuCure, I continue to have occupational exposure to blood or other potentially infectious <br />materials and I want to be. vaccinated with Hepatitis B vaccine, Imay do so, <br />Refeiencee Appendix A, Z9 Cone of Federal Regulations 1910.1030 Ocenpatioital <br />lxposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />I,n �C�/\-^V^ t " r�^i e decided not to receive injections of <br />QjriQ name) <br />Date <br />I:\Policy and Legffi CHP\Herilth Forws,Crim 131grd Chcic, dung sereen, fingerprint for StudentslTTealth <br />Foitns 2017.2012\Hep R Vaccine Decline Fonn.do4 <br />