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DocuSign Envelope ID:79C5D167-B6CA-4E59-B4AC-AA38CC1 B20BD <br /> Orange County Emergency Services <br /> Exposure Control Policy ` ` <br /> Treatment Declination Form <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, <br /> hepatitis C virus (HCV) infection or any other bloodborne disease. I have been given <br /> the opportunity to be evaluated and treated as necessary, at no charge to my self. <br /> However, I decline such treatment at this time. I understand that by declining this <br /> treatment, I could be at risk of acquiring any known bloodborne disease or any potential <br /> complication from this injury / exposure. <br /> By signing below I release Orange County Emergency Services and its personnel from <br /> any responsibility whatsoever, should I contract any disease, infection or disability from <br /> this injury/ exposure. <br /> Signature <br /> Date <br /> Revised July,2018 <br />