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Revised -XO\ <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 />___________________________________ <br />Signature <br />___________________________________ <br />Date <br />Orange County Emergency Services <br />Exposure Control Policy <br />Treatment Declination Form <br />DocuSign Envelope ID: 79C5D167-B6CA-4E59-B4AC-AA38CC1B20BD