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HEPATITIS B VACCINE DECLINATION <br /> understand that du a to my occupational exposure to blood or other potentially infectious <br /> materials I may be. at risk of acquiring hepatitis B virus (HBV) infection. I have been given the <br /> opportunity to be vai;cinated with hepatitis B vaccine, at no charge to myself. However, I decline <br /> hepatitis B vacciral i m at this time. I understand that by declining this vaccine, I continue to be at <br /> risk of acquiring h)e mtitis B, a serious disease. If in the future I continue to have occupational <br /> exposure to blood o-other potentially infectious materials and I want to be vaccinated with <br /> hepatitis B vaccine I can receive the vaccination series at no charge to me. <br /> Print Name: (First, -ast, MI) -ritle <br /> '��-d4--:24 /d2,11 1-2,�)2, <br /> Sig ature Date <br /> i <br />