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VACCINATION DECLINATION FORM by cGJesg9

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									    PLEASE PRINT/SIGN & BRING TO 1ST DAY OF CLASS

        CENTRAL CAROLINA COMMUNITY COLLEGE
                  CHATHAM COUNTY
                    NURSE AIDE II
           VACCINATION DECLINATION FORM


STUDENT:


LAST 4 Digits Social Security Number:




       I understand that due to my potential exposure to blood or other
potential infectious materials during my Nurse Aide II clinical, I may be
at risk of acquiring Hepatitis B virus (HBV) infection.

I have been given information regarding the virus and the vaccine;
however, I DO decline the vaccination at this time. I understand that by
declining this vaccine, I continue to be at risk of acquiring Hepatitis B.
If I desire to receive the vaccination later, I may do so at my own
discretion and my own expense.




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Student Signature                                     Date



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Instructor Signature                                  Date

								
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