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Transcript
HEPATITIS B VACCINE DECLINATION
I understand that due to my occupational exposure to blood or other
infectious materials that I may be at risk of acquiring Hepatitis B virus
infection. I have been given the opportunity to be vaccinated with the
Hepatitis B vaccination at this time. I understand that by declining this
vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease.
If in the future I continue to have occupational exposure to blood or
potentially infectious materials and I want the Hepatitis B vaccine, I can
receive the vaccination series as no charge to me.
_________________________________
(Signature)
_________________________________
(Print Name)
_________________________________
(Title)
_________________________________
(Date)
_________________________________
(Department Name)
Declination Form – Hepatitis B Rev. 8/2011