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I understand that due to my occupat onal exposure to blood or oflier potentially infectious <br />materials I may be at risk of acgrmmg 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 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: <br />Appendix A, <br />29 Code of Federal Regulations <br />1910.1030 Occupational <br />Exposure <br />to Bloodborne <br />Pathogens. Occupational Safety <br />and Health Act. <br />I, ,have decided not to receive injections of <br />(Prurt Name) <br />Date Signiattue <br />I:�Policy and Legal CHP�I-Iea1tU Ponns,Czim Bkgrd Chcic, drug screen, fingerprint for Students�Eiealtli <br />Forms 20l L2012�I3ep B Vaccine Decline Form:doc <br />