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Bloodborne Pathogen Exposure Evaluation Form*

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 # _________________
  3. Home Phone # ___________________
  4. Job Title: ________________________
  5. Date of Exposure:_________________
  6. See Exposure Report for circumstances under which exposure incident occurred.
  7. 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).

 

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