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Facility ID# <br />Pro ram ID# <br />Hepatitis B Declination Statement <br />i understand that due to my occupational exposure to blood or other potentially <br />infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I <br />have read and understand the health risks involved with Hepatitis B; however, I <br />voluntarily decline Hepatitis B vaccination at this time. I fully understand the risk of its <br />transmission and have full knowledge of its effects on the human body. I understand <br />that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious <br />disease. <br />SIGNATURE: <br />PRINT NAME: <br />,M <br />DATE: 10 I23 _ <br />ADDRESS: 1'25 S061I2lA61- _ CITY: q) f STATE Ct4 ZIP CGjQ3Z <br />W-NUM1EN-PROGRAMS 6 PROJECTSWDY ARi1FORMSIWORO DOOSMREPATrIS 8 DECLINATION STATEMENT, 4 23 13.dom <br />l <br />