Health Care Professionals
Written Opinion For Post-Exposure Evaluation*
- Employee Name:______________________________________________
- Date of Incident:_____________________________________________
- Date of Office Visit:___________________________________________
- Health Care Facility
Address: ___________________________________
- Health Care Facility Telephone: _________________________________
As required under the
Bloodborne Pathogen Standard:
______ The employee
named above has been informed of the results of the post-exposure
health evaluation.
______ The employee
named above has been told about any health conditions resulting from
exposure to blood or other potentially infectious materials which
require further evaluation or treatment.
______ Hepatitis B
vaccination is ____ is not ____ indicated.
Signature of health care provider:_______________________ Date:
________
Printed or typed name of health care
provider:___________________________
This form is to be returned to the employer, and a copy provided to
the employee within 15 days.
Employer Name:______________________________
Title:_______________________________________
Address:_________________________________________________________
*This form was taken from: Model Exposure Control Plan for
Home Care: A Guide for Hospice/Home Agencies on the Bloodborne Pathogens Standards.
OSHA Office of Occupational Nursing, 1994.
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