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 Number:_____________ Date of
Birth:_______________
- Home
Phone:______________________
- Job Title:
_________________________
- 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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