Laserfiche WebLink
Og LOS, <br /> Public Nealth <br /> COUNTY OF LOS ANGELES—DEPARTMENT OF PUBLIC HEAL- <br /> ENVIRONMENTAL HEAI.TfF <br /> BODY ART INSPECTION PROGRAM <br /> -ioluntary 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 (HBV) <br /> infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine. a'. <br /> no charge to myself. However, I decline hepatitis B vaccination at this time. I understand <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 I <br /> want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no <br /> charge to me. <br /> 1b 16U <br /> Date: <br /> TwAwm <br /> Print Name bignature--------� <br /> Government issued identification: <br /> Drivers license#&state: U <br /> Passport#& country: <br /> Others: <br /> 'COTE:The owner of the body art facility where the body art practitioner works is responsible for <br /> ,proviaing the vaccination series at no cost.The County of Los Angeles does not provide this <br /> service. <br /> ifa 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 /> 4120/2016 <br />