Form DHHS-1468 Body Art Facility Inspection Report Form - Michigan

Form DHHS-1468 is a Michigan Department of Health and Human Services form also known as the "Body Art Facility Inspection Report Form". The latest edition of the form was released in May 1, 2016 and is available for digital filing.

Download an up-to-date Form DHHS-1468 in PDF-format down below or look it up on the Michigan Department of Health and Human Services Forms website.

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PAGE 1 of ____
Body Art Facility
Inspection Report Form
NON-TRANSFERABLE
LICENSE NUMBER:
DHHS-1468 (05-16)
AUTHORITY: P.A. 375 OF 2010
TECHNICIAN & PATRON:
FACILITY NAME
STREET ADDRESS
CITY VILLAGE OR TWP/ZIP
COUNTY
FACILITY TYPE:
MDEQ Certification #
_________________
#
MUNICIPAL WATER:
Y N
MUNICIPAL SEWER:
Y N
OWNER:
OPERATOR:
PHONE NUMBER
DATES OF OPERATION:
Notice to Operator:
gpaez@ioniacounty.org
INSPECTION TYPE
Non-critical items listed below must be corrected by the next regular inspection or as
Pre-Opening Inspection……..….1
otherwise indicated. All
critical
items shall be corrected immediately or as otherwise
Opening Inspection………..…....2
Routine Inspection……..….…....3
indicated.
(Michigan Public Health Code, Act 368 of 1978)
Follow-Up…………………........4
√ = COMPLIANT X= NON-COMPLIANT NA = NOT APPLICABLE
KEY:
Complaint…………………..…...5
REFERENCES FOR RULES: ALL BEGIN WITH R.333.XXXXX, Rule X
Other………………………….....6
CRITICAL VIOLATIONS:
CRITICAL VIOLATIONS:
1.____ __REFERRALS TO MIOSHA Rule 7
32.____PROCEDURE AREA SEPARATE FROM
2.______ REFERRALS TO MDEQ Rule 15, (1, 2)
CUSTOMER AREA Rule 16, (3)
3.______TECHNICIAN TRAINING/ EDUCATION Rule 7, (2)
33.____SEPARATE ROOM FOR CLEANING,
4.______GLOVE USAGE Rule 9
DISINFECTING AND STERILIZING Rule 16, (10)
5.______SINGLE-USE ITEMS Rule 12
34.____ SELF-CLOSING DOORS Rule 16, (2)
6.______STENCILS / SKIN PRODUCTS Rule 12, (8)
35.____WALLS, FLOORS, CEILINGS, SURFACES CLEAN
7.______INSTRUMENT STERILE PACKAGE Rule 14, (10)
& GOOD REPAIR Rule 16, (5)
8.______SKIN PREPPED Rule 12, (2)
36.____LAVATORY AND HAND WASHING Rule 16, (8, 9)
9.______NON-INTACT SKIN Rule 9, (2)
37.____LAVATORY WITH HAND SINK, TOILET,
10._____HAND WASH SINK Rule 16, (8)
COVERED WASTE RECEPTICLE Rule 16, (19)
11._____PROCEDURE AREA ORGANIZED Rule 12, (1)
38.____CONTAINERS PROPERLY LABELED Rule 16, (12)
12._____USED INSTRUMENTS Rule 12, (7)
39.
____BACK FLOW/BACK SIPHONAGE PREVENTION
13._____ULTRASONIC UNIT Rule 14, (4)
Rule 16, (19)
14._____SPORE TESTING Rule 14, (13)
40.____HEP B VACCINATION STATUS OR
15._____TECHNICIAN UNDER THE INFLUENCE-PA 375, Sec.13112
DECLINATION DOCUMENTED Rule 8, (1), (a)
16._____TECHNICIAN HYGIENE Rule 9, (4)
17._____SELLING/ GIVING KIT OR PIERCING DEVICE TO A
MINOR-PA 375, Sec. 13110
NON-CRITICAL VIOLATIONS:
18._____CLIENTS UNDER THE INFLUENCE Rule 9, (3)
41.____CURRENT LICENSE POSTED IN CUSTOMER
19._____WRITTEN CONSENT OF PARENT OR GUARDIAN FOR
SERVICE AREA Rule 3, (8)
CLIENTS UNDER 18 PA 375, Sec. 13102
42.____VERBAL AND WRITTEN AFTERCARE
20._____NO ANIMALS, INSECTS OR VERMIN Rule 16, (15)
21._____NO SMOKING AND SIGN POSTED PA 375, Sec.13107, (g)
MATERIALS PROVIDED Rule 1, (c)
22._____JEWELRY STERILIZED IMPLANT GRADE Rule 12, (17)
43.____TECHNICIAN AND CLIENT RECORDS MEET
23._____ROTARY PEN CLEANED AND STERILIZED Rule 12, (15)
MINIMUM.STANDARDS PA 375, Sec.13107
24._____PIGMENT/ INK BOTTLES STORED Rule 12, (13)
44.____REQUIRED FORMS SIGNED BY CLIENT AND
25._____WASTE CONTAINERS COVERED & CLEAN Rule 16, (13)
TECHNICIAN Rule 6, (1, 2)
26._____CLEAN/ DISINFECT PROCEDURE AREA Rule 16, (6)
45.____RECORD OF ALL BODY ART PROCEDURES
27._____CLEAN AND STERILIZE OBJECTS EXPOSED TO OPIM
PERFORMED PA 375, Sec. 10107
Rule 9, (22)
46.____DISCLOSURE STATEMENT, NOTICE FOR FILING
COMPLAINTS, FACILITY RECORDS KEPT
28._____SAFE PRACTICES Rule 9, (4)
CONFIDENTIAL AND SECURE Rule 11, (1)
29._____LIGHTING PROVIDED Rule 16, (7)
47.____SUPPLY INVENTORY AVAILABLE PA 375,
30._____FLOOR SPACE PROCEDURE AREA Rule 16, (4)
Sec. 13107, Pg. 5, (C)
31._____WELL VENTILATED Rule 16, (2)
Received by: __________________________
Inspected by: ________________________
Date ____/____/______
PAGE 1 of ____
Body Art Facility
Inspection Report Form
NON-TRANSFERABLE
LICENSE NUMBER:
DHHS-1468 (05-16)
AUTHORITY: P.A. 375 OF 2010
TECHNICIAN & PATRON:
FACILITY NAME
STREET ADDRESS
CITY VILLAGE OR TWP/ZIP
COUNTY
FACILITY TYPE:
MDEQ Certification #
_________________
#
MUNICIPAL WATER:
Y N
MUNICIPAL SEWER:
Y N
OWNER:
OPERATOR:
PHONE NUMBER
DATES OF OPERATION:
Notice to Operator:
gpaez@ioniacounty.org
INSPECTION TYPE
Non-critical items listed below must be corrected by the next regular inspection or as
Pre-Opening Inspection……..….1
otherwise indicated. All
critical
items shall be corrected immediately or as otherwise
Opening Inspection………..…....2
Routine Inspection……..….…....3
indicated.
(Michigan Public Health Code, Act 368 of 1978)
Follow-Up…………………........4
√ = COMPLIANT X= NON-COMPLIANT NA = NOT APPLICABLE
KEY:
Complaint…………………..…...5
REFERENCES FOR RULES: ALL BEGIN WITH R.333.XXXXX, Rule X
Other………………………….....6
CRITICAL VIOLATIONS:
CRITICAL VIOLATIONS:
1.____ __REFERRALS TO MIOSHA Rule 7
32.____PROCEDURE AREA SEPARATE FROM
2.______ REFERRALS TO MDEQ Rule 15, (1, 2)
CUSTOMER AREA Rule 16, (3)
3.______TECHNICIAN TRAINING/ EDUCATION Rule 7, (2)
33.____SEPARATE ROOM FOR CLEANING,
4.______GLOVE USAGE Rule 9
DISINFECTING AND STERILIZING Rule 16, (10)
5.______SINGLE-USE ITEMS Rule 12
34.____ SELF-CLOSING DOORS Rule 16, (2)
6.______STENCILS / SKIN PRODUCTS Rule 12, (8)
35.____WALLS, FLOORS, CEILINGS, SURFACES CLEAN
7.______INSTRUMENT STERILE PACKAGE Rule 14, (10)
& GOOD REPAIR Rule 16, (5)
8.______SKIN PREPPED Rule 12, (2)
36.____LAVATORY AND HAND WASHING Rule 16, (8, 9)
9.______NON-INTACT SKIN Rule 9, (2)
37.____LAVATORY WITH HAND SINK, TOILET,
10._____HAND WASH SINK Rule 16, (8)
COVERED WASTE RECEPTICLE Rule 16, (19)
11._____PROCEDURE AREA ORGANIZED Rule 12, (1)
38.____CONTAINERS PROPERLY LABELED Rule 16, (12)
12._____USED INSTRUMENTS Rule 12, (7)
39.
____BACK FLOW/BACK SIPHONAGE PREVENTION
13._____ULTRASONIC UNIT Rule 14, (4)
Rule 16, (19)
14._____SPORE TESTING Rule 14, (13)
40.____HEP B VACCINATION STATUS OR
15._____TECHNICIAN UNDER THE INFLUENCE-PA 375, Sec.13112
DECLINATION DOCUMENTED Rule 8, (1), (a)
16._____TECHNICIAN HYGIENE Rule 9, (4)
17._____SELLING/ GIVING KIT OR PIERCING DEVICE TO A
MINOR-PA 375, Sec. 13110
NON-CRITICAL VIOLATIONS:
18._____CLIENTS UNDER THE INFLUENCE Rule 9, (3)
41.____CURRENT LICENSE POSTED IN CUSTOMER
19._____WRITTEN CONSENT OF PARENT OR GUARDIAN FOR
SERVICE AREA Rule 3, (8)
CLIENTS UNDER 18 PA 375, Sec. 13102
42.____VERBAL AND WRITTEN AFTERCARE
20._____NO ANIMALS, INSECTS OR VERMIN Rule 16, (15)
21._____NO SMOKING AND SIGN POSTED PA 375, Sec.13107, (g)
MATERIALS PROVIDED Rule 1, (c)
22._____JEWELRY STERILIZED IMPLANT GRADE Rule 12, (17)
43.____TECHNICIAN AND CLIENT RECORDS MEET
23._____ROTARY PEN CLEANED AND STERILIZED Rule 12, (15)
MINIMUM.STANDARDS PA 375, Sec.13107
24._____PIGMENT/ INK BOTTLES STORED Rule 12, (13)
44.____REQUIRED FORMS SIGNED BY CLIENT AND
25._____WASTE CONTAINERS COVERED & CLEAN Rule 16, (13)
TECHNICIAN Rule 6, (1, 2)
26._____CLEAN/ DISINFECT PROCEDURE AREA Rule 16, (6)
45.____RECORD OF ALL BODY ART PROCEDURES
27._____CLEAN AND STERILIZE OBJECTS EXPOSED TO OPIM
PERFORMED PA 375, Sec. 10107
Rule 9, (22)
46.____DISCLOSURE STATEMENT, NOTICE FOR FILING
COMPLAINTS, FACILITY RECORDS KEPT
28._____SAFE PRACTICES Rule 9, (4)
CONFIDENTIAL AND SECURE Rule 11, (1)
29._____LIGHTING PROVIDED Rule 16, (7)
47.____SUPPLY INVENTORY AVAILABLE PA 375,
30._____FLOOR SPACE PROCEDURE AREA Rule 16, (4)
Sec. 13107, Pg. 5, (C)
31._____WELL VENTILATED Rule 16, (2)
Received by: __________________________
Inspected by: ________________________
Date ____/____/______
VIOLATION DESCRIPTION / REMARKS / CORRECTION SCHEDULE
Page 2 of ____
LICENSE NUMBER:
Received by: __________________________
Inspected by: ________________________
Date __/__/____

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