Body Art Facility Inspection Report Form printable pdf download

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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:

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:

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 ____/____/______

Body Art Facility Inspection Report Form

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