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Student Hepatitis B Vaccine declination <br />i understand that clue to my occupational exposure to blood or other potentially infecdous <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (I -IBV) infectious. <br />i fowever, I decline I lepatitis B vaccination at (Itis time. I understand that by declining <br />this vaccine, I continue to be at risk of acquiring 1-Icpatilis 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 Occupational <br />)✓xposao Bfloodborne Pathogens. Occupational Safety and Health Act. <br />I, C Y6 ✓ �� �h�2� , have decided not to receive injections of <br />(Print Name) <br />Daie Signa e <br />1:1Policy and lAgal CHPU-lealth Furms,Crhn Bkgrd Chek, drug screen, fingerprint for Studentslllealth <br />Forms 2011.2012\1lep R Vaccine Decline Fonn.doc <br />