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L <br /> RE�VVED <br /> tos +� <br /> L <br /> AV a <br /> bi <br /> E IRONENTAL HEALTH <br /> ' <br /> Y PE ITISERVICES <br /> �Y <br /> ® <br /> C,e 6 <br /> C4LIF pRN\P pu Yppftets <br /> COUNTY OF LOS ANGELES—DEPARTMENT OF PUBLIC HEALTH <br /> ENVIRONMENTAL 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 (HBV) <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 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 /> Date: <br /> Print Name`J Signature <br /> Government issued identification: <br /> Drivers license # & state: t. t <br /> Passport# & country: <br /> Others: <br /> NOTE: The owner of the body art facility where the body art practitioner works is responsible for <br /> providing the vaccination series at no cost. The County of Los Angeles does not provide this <br /> service. <br /> If 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 /> 4/20/2016 <br />