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* 1. Please select the school or department in which you qualify.

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* 2. Last Name

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* 3. First Name

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* 4. I have read and understand the information presented in this program regarding Bloodborne Pathogens and Universal Precautions.

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* 5. I am interested in receiving the Hepatitis B Vaccine.

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* 6. According to my job descritption I fall into the high risk category outlined by Yorktown Community Schools Bloodborne Pathogens Policies.

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