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4100 – Safe Body Art
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PR0547618
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COMPLIANCE INFO
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Last modified
7/20/2023 9:36:14 AM
Creation date
6/27/2023 8:51:51 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
PR0547618
PE
4110
FACILITY_ID
FA0027105
FACILITY_NAME
SALON DE BELLEZZA (ALVAREZ CORTES, ARELY)
STREET_NUMBER
5940
STREET_NAME
PACIFIC
STREET_TYPE
AVE
City
STOCKTON
Zip
95207
CURRENT_STATUS
01
SITE_LOCATION
5940 PACIFIC AVE
P_LOCATION
01
QC Status
Approved
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SJGOV\cfield
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EHD - Public
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I understand that due to riiy occupational exposure to Ulood or other potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious. <br />However, I decline Hepatitis.B vaccination at this time. I understand that by declining <br />this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the <br />future, I continue to have occupational exposure to blood or other potentially infectious <br />materials and I want to be vaccinated with Hepatitis B vaccine, 1 may do so. <br />Reference: Appendix A, 29 Cade of Federal Regulations 1910.1030 Occupational <br />Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />I, V .P t- ,have decided not to receive injections of <br />lint Nam ) <br />Date <br />Signature <br />I:�Policy and Legal CHPlI3ealtki Porms,Crim Bkgid CUck, drug screen, fingerprint for Students�IIealth <br />Forms 2011 ?017_,I-Iep B Vaccine Decline Poxan.doc <br />
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