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<br />HEPATITIS B IMMUNIZATION RECORD <br /> <br />Name of Facility <br /> <br />Address <br /> <br />Name of Owner <br /> <br />Name of operator <br /> <br />Hire Date <br /> <br />Date of Birth <br /> <br />S/S# <br /> <br />Hepatitis B Immunization Record: <br /> <br />Date 151 shot Shot given by Facility <br />Date 2nd shot Shot given by Facility <br />Date 3rd shot Shot given by Facility <br /> <br />-The Hepatitis B documentation must be kept on file at the Establishment and a copy given to the <br />regulatory authority. A photocopy of the operators CPR certificate should also appear on this form. <br />