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Technical Links > Nursing Home > Nursing Home eCAT  > BBP Module > Exposure Evaluation

 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.)

  1. Employee Name:___________________ Today's Date:_______________
  2. Social Security Number:_____________ Date of Birth:_______________
  3. Home Phone:______________________
  4. Job Title: _________________________
  5. Date of Exposure: __________________

(See Exposure Report for circumstances under which exposure incident occurred)

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 sources 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.


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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