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Student i`l`epLa- t-is B VaICtChI e DeeMnatr io <br /> i understand that due,to my occupational exposure to blood or other potentially infectious <br /> materials I maybe at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious. <br /> However,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 serous 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 Occupational <br /> Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br /> I, Ou'a--c�V \��: (\ , have decided not to receive injections of <br /> (Print Name) <br /> O <br /> Date Signature <br /> IAPolicy and Legal CHPU-1calth Forms,Crim Bkgrd Chek,drug screen,fingerprint for Stu dentsTealth <br /> Forms 2011.2012\I3ep B Vaccine Decline Foru.doc <br />