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COMPLIANCE INFO
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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E
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ELEVENTH
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18
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4100 – Safe Body Art
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PR0548554
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COMPLIANCE INFO
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Entry Properties
Last modified
11/19/2024 10:19:27 AM
Creation date
8/11/2023 1:51:26 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
PR0548554
PE
4110
FACILITY_ID
FA0027759
FACILITY_NAME
IN BLOOM TATTOO & PIERCING (IBARRA, AMBER)
STREET_NUMBER
18
Direction
E
STREET_NAME
ELEVENTH
STREET_TYPE
ST
City
TRACY
Zip
95377
CURRENT_STATUS
01
SITE_LOCATION
18 E ELEVENTH ST
P_LOCATION
03
QC Status
Approved
Scanner
SJGOV\cfield
Tags
EHD - Public
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m PACIFIC <br />HEPATITIS (B) VACCINATION PROGRAM <br />Acceptance Option: <br />❑ I wish to be provided the opportunity to undergo the Hepatitis B vaccination <br />protocol. <br />Declination Option # 1: <br />❑ I understand that due to my occupational exposure to blood or other potentially <br />infection materials (OPIM), I may be at risk of acquiring Hepatitis B virus (HBV) <br />infection. I have been given the opportunity to be vaccinated with Hepatitis B <br />vaccine, at no charge to me. My employer has advised that OSHA regulations <br />recommend that all dental personnel having patient contact should receive the <br />Hepatitis B vaccination. <br />However, I decline Hepatitis B vaccination at this time. I understand that by <br />declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious <br />disease. If in the future I continue to occupational exposure to blood or OPIM <br />and I want to be vaccinated with Hepatitis B vaccine, I need to notify my <br />supervisor, or a member of my Safety Committee, so that I can receive the <br />vaccination series at no charge to me. <br />Declination Option # 2: <br />ecline to undergo the Hepatitis B vaccination as I have had it in the past. <br />,()//A�h� <br />Date <br />Print Name <br />Signature <br />
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