Bloodborne
Pathogen Exposure Evaluation Form
Send with employee at the time a health evaluation is needed. Form to be
completed and kept by health care provider only. Information on this form is
confidential. Do not send this form to employer.
- Employee Name:_________________ Today's Date: _____________________
- Social Security # _________________
- Home Phone # ___________________
- Job Title: ________________________
- Date of Exposure:_________________
- See Exposure Report for circumstances under which exposure incident occurred.
Source of exposure:_________________________________________________
Yes
|
No
|
Blood of source individual has been tested with consent of
individual as applicable. If no, please explain and/or indicate if HIV and/or HBV is
already known.
_______________________________________
|
Yes
|
No
|
Results of source individual's testing conveyed to
employee. (Explain)________________________________
|
Yes
|
No
|
Employee informed of applicable laws and regulations
concerning disclosure of the identity and infectious status of the source.
(Explain)________________________________
|
Yes
|
No
|
Exposed employee's blood collected and tested with obtained
consent. (Explain)_________________________________
|
Yes
|
No
|
If employee declines HIV testing, blood stored for 90 days
from exposed incident. (Explain)_________________________________
|
Yes |
No |
Post-exposure prophylaxis initiated if medically indicated.
(Explain)_________________________________
|
Yes |
No |
Hepatitis B vaccination is indicated. Elaborate on treatment
given:__________________________ |
|
Status of employee vaccination:
One of three: Date________ Type__________ Lot#__________Site_______
Administered by:________________________________________________
Two of three: Date________ Type__________ Lot#__________Site______
Administered by:________________________________________________
Three of three: Date________ Type__________ Lot#__________Site_____
Administered by:________________________________________________
Yes / No Employee informed of results of evaluation. (Explain)_________
Yes / No Employee has been informed of any health conditions resulting
from exposure to blood or other potentially infectious materials which require further
evaluation or treatment. (Explain)______________________________________________________
Assessment/Observations/Plan:
_____________________________________________________________
_____________________________________________________________
Action: _____ Confidential post-exposure evaluation entered into
employee's individual
health record.
_____ Copy of
health care professional's written opinion for post-exposure
evaluation completed and sent to employer.
_____ Copy of
health care professional's written opinion for post-exposure
evaluation given to employee.
NOTE: all other findings shall remain confidential and shall not
be included.
*Taken From: Model Exposure Control Plan for
Home Care: A Guide for Hospice/Home Agencies on the Bloodborne Pathogens Standard.
Appendix A, A-3, OSHA Office of Occupational Nursing (1994). |