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Student 1riepatids B Vaccine Dedination <br /> I understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I may be 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 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 /> Exposure to Bl odUorn Pathogens. Occupational Safety and Health Act. <br /> MJ G <br /> CA ei ,have decided not to receive injections of <br /> (1'riut Name) <br /> Date Slanature <br /> I:\Policy and Legal CHP\Health Forms,Crini Bkgrd Chck,drug screen,fingerprint for StudentAFIcalth <br /> Forms 2011.2012\Hep B Vaccine Decline Form.doc <br />