Employment Information
This form may be used to document the employment records as required in the Douglas County Health Department Body Art Regulations, 22-02. The following information for each employee of a Body Art Establishment shall be on file and available for inspection by DCHD at all times during operating hours:
Employee full legal name:
First Name
Middle Name
Last Name
Employee identifier name (i.e. Nickname), if applicable:
Employee home address:
Employee home phone number:
Please enter a valid phone number.
Date of hire:
-
Month
-
Day
Year
Date
Bloodborne Pathogen Course (BA-22-02, Section 2-101):
Hepatitis B Vaccine (BA-22-02, Section 2-101):
OR
Employee Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: