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Orange County Emergency Services <br />Hepatitis B Vaccination Declination <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 />________________________________ _____ _________________ <br />Print Name Date <br />______________________________________ __________________ <br />Signature Date <br />______________________________________ __________________ <br />Name of Witness Date <br />_______________________________________ __________________ <br />Signature of Witness Date <br />Revised -XO\ <br />DocuSign Envelope ID: 79C5D167-B6CA-4E59-B4AC-AA38CC1B20BD