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COMPLIANCE INFO
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4100 – Safe Body Art
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PR0547547
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COMPLIANCE INFO
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Entry Properties
Last modified
7/20/2023 9:05:38 AM
Creation date
6/27/2023 8:59:20 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
PR0547547
PE
4110
FACILITY_ID
FA0027043
FACILITY_NAME
SALON DE BELLEZZA (NGUYEN, TU)
STREET_NUMBER
5940
STREET_NAME
PACIFIC
STREET_TYPE
AVE
City
STOCKTON
Zip
95207
CURRENT_STATUS
02
SITE_LOCATION
5940 PACIFIC AVE STE C
P_LOCATION
01
QC Status
Approved
Scanner
SJGOV\cfield
Tags
EHD - Public
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�irn���e�nti IFle�ea�nti� 1� ����nLrne ��c�saaL$®n <br />I understand that due to my occupational exposure to blood or other potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (I -MV) 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 acquhing 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, I may do so. <br />Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br />Exposure to Bloodborne pathogens. Occupational Safety and Health Act. <br />I, TU C� N G YEIN/ have decided not to receiveinjections of <br />(flint Name) <br />0 <br />Date <br />I:�Policy and Legal CIIPU�ealtli Forms,Crim Bk, d Chck, drug screen, fingerprint for Smdents�iiealth <br />Fotvrs 2011.2012�I3ep R Vaccine Decline Fonu.doc <br />
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