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Student 1riepatitns 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 CI,G� V ,have decided not to receive injections of <br />(1'riut Name) <br />dfa(' P < � L - <br />Date <br />S��nature <br />I:\Policy and Legal CHP\Health Forms,Crim Bkgrd Chck, drug screen, fingerprint for StudentAFIcalth <br />Forms 2011.2012\Hep B Vaccine Decline Form.doc <br />