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�aL��t3_e �iE;p �iiif� � ��2aE'.FnTi:L fiDe��°ilat'e Orl <br />I tindersKtnd that clue to my occupafioi�al ekpt�sute to blood of other potentially infe<airnt's <br />materials I may be, at ride of accluhing or transmitting Hepatitis B virus (HBV) infections. <br />However, I decline Hepatitis B vaccination at ibis time. 1 understand that by declining <br />this vaccine. I continue to be at risk of acgttiTing Hepatitis B, a serious disease. If, in the <br />future, I eoil,tinne to have occopational exposure to blood or other potentially infectious <br />materials and I want to be vaccinated 4viflt Hepatitis B vaccine, I may do so. <br />Referetities Appendix A, 29 Cocle of Pedercil Reaulatious I91q.1030 Ocegpati6na7 <br />Bxposur1e, to Hloodboxne Pathogens. Occupational Safety and Hcaltb Act. <br />`U mm have decided not to receive injectim.s of <br />(Print N` nle) <br />I:u olicy and Legal CHP1Healtlt Portns,Critn T3kgrrl Click, drug screen, fingcryrint for Students5tlea][h <br />ltonns 2Ql J 3012\Hep R Vaccine Dec? rue rorntdor. <br />