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Hepatitis B Declination Form Employee Name: ___________________________ Date of Birth: ______________________________ Department: Job Title: I understand that due to the possibility for occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring hepatitis virus (HBV) infection. I have been given the opportunity to receive the Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I may continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me. Employee Name (print): Date: Employee Signature: Supervisor Name (print): Supervisor Signature: Date: