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Student HepatitisB Vacefivic Dechn-alion <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 (14BV) infectious. <br />C) <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 />FAposure to Bloodhorne Pathogens. Occupational Safety and Health Act. <br />L — h tj 1 p64 have decided not to receive injections of <br />(Print Name) <br />041%4 <br />(APolicy and Legal CHI'Vical0i Furms,Crim 11kgrd Click, drug screeii, fingerprint for StudentsWcalth <br />Forms 2011.20124Hel) 8 Vaccine Decline l,'o, <br />