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DocuSign Envelope ID:79C5D167-B6CA-4E59-B4AC-AA38CC1 B20BD <br /> �t'"g` ' car/ <br /> � Orange County Emergency Services ' <br /> x +tt <br /> Hepatitis B Vaccination Declination <br /> ,o ; <br /> I understand that due to my occupational exposure to blood or other potentially <br /> infectious materials that I may be at risk of acquiring hepatitis B virus (HBV) infection. I <br /> have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge <br /> to myself. However, I decline hepatitis B vaccination at this time. I understand that by <br /> declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. <br /> If in the future I continue to have occupational exposure to blood or other potentially <br /> infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive <br /> the vaccination series. <br /> Print Name Date <br /> Signature Date <br /> Name of Witness Date <br /> Signature of Witness Date <br /> Revised July, 2018 <br />