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Name
   
I have received the complete Hepatitis B Vaccination Series
    Employee Signature
Date
  

Declination Statement:

 

               
I decline 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.  I understand that due to my occupational exposure to blood and other potentially infectious material, I may be at a higher risk of acquiring Hepatitis B.  However, if in the future, I continue to have occupational exposure to blood or other potentially infectious materials and want to be vaccinated with the Hepatitis B Vaccine, I will receive the Vaccination series at that time.