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Facili ID# <br /> .Pro ram ID# <br /> "fHepatitis B Declination Statement <br /> :I understand that due to-<my occupational exposure to blood or other potentially =; <br /> 'infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I <br /> f.have read and understand' the health risks involved with,`Hepatitis B; however, 1 <br /> gMvoluntarily decline Hepatitis*B vaccination at this time. I fully:understand the risk of its <br /> ':transmission and have full. nowledge of its effects. on the human body. i understand <br /> Ghat by declining this vaccine I continue to be at risk of acquiring Hepatitis B,.a serious <br /> disease. <br /> SIGNATURE: DATE: <br /> PFRINT NAME: <br /> ADDRESS: CITY: STATE - ZIP <br /> , i <br /> -'i <br /> ��"h.�0at*%EM-PROGWIMS&PROJEC S%BO0Y ARWORMSWO(t'OOMKEPA7MS b OEGLWAMON STATEMENT,4 2343400 <br /> . t <br /> t y , <br />