DECLINATION

I am refusing the Hepatitis B Vaccine and hold harmless PassportUSA, Health Carousel, LLC, and its partner organizations. I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B Vaccination.

I decline Hepatitis B Vaccination at this time. I understand that by declining the vaccine, I continue to be at risk for acquiring Hepatitis B, a serious disease. If in the future, while actively employed by Health Carousel and its partner organizations, I continue to have occupational exposure to blood and other potentially infectious materials and want to be vaccinated with the Hepatitis B Vaccine, I can do so.