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0 0 <br /> Hepatitis B Vaccine Declination Form <br /> MEM <br /> Facility Name: LO Ck i M� <br /> I understand that due to my occupational exposure to blood or other potentially <br /> infectious materials (OPIM), I may be at risk of acquiring hepatitis B virus (HBV) <br /> infection. <br /> You have given me the opportunity to be vaccinated with the hepatitis B vaccine, at <br /> no charge to myself. <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, <br /> in the future, I continue to have occupational exposure to blood or other potentially <br /> infectious materials, and I want to be vaccinated with hepatitis B vaccine, I can <br /> receive the vaccination series at no charge to me. <br /> 0 1 have already received the hepatitis B vaccination series. <br /> 12a thie <br /> Employee s Na7 (Plio� I I <br /> �Ioyee'srlg4t—ure A (B&ca. • <br /> 209-327-6342 <br /> Date <br /> dj <br /> http://www.Ini.wa.gov/ <br /> R-6 <br />