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COUNTY" OF SACRAMENTO - DEPARTMENT OF P1 IBLIC F-I <br /> OENVIRONMENTAL HEALTH ` <br /> BODY ART INSPECTION PROGRAM , <br /> Voluntary Declination of Hepatitis B Vaccination` <br /> I understand that due to my occupational exposure to blood or other potentially <br /> infectious material (OPIM) I may be at risk of acquiring the hepatitis B virus (HBA'" <br /> infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at <br /> no charge to myself. However, I decline hepatitis B vaccination at this time. I unerstan <br /> that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious' <br /> disease. If in the future I continue to have occupational exposure to blood or OPIM and <br /> want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no <br /> charge to me-, ' <br /> Date: - 2- <br /> Print Name Signature <br /> 8overnment issued identification: <br /> Drivers license # & state: -),S <br /> Passport# & country: <br /> Others: <br /> �:.. . . .a_ : ... <br /> . , NOTE: The owner of the body art facility where the body art practitioner works is responsible <br /> r: or providing the vaccination series at no cost. The County of Sacramento does not provide tli <br /> service. <br /> a practitioner declines the hepatitis B vaccination, a copy of this declination must be submitted <br /> with the Body Art Practitioner Registration Form and provided to the operator of each location <br /> where the practitioner performs body art, <br />