Download Source Patient Information Form

Source Person Name: _________________________ ________
Date of Birth: _______________
Internal Use - Cut here
Please FAX both forms directly to your Concentra location.
Bloodborne Pathogen Exposure
Source Person Information
EP Chart Number (Concentra Internal Use Only):_______________
This Source Person Information form neither intends to, nor in any way suggests that, Concentra is ordering, approving, or
demanding certain medical or laboratory tests, vaccinations, or other such services. We are requesting this information about the
source person so we can better treat the exposed person.
 If source is unknown, document exposed person’s name on bottom of this form.
 Source known  If known, complete the following section and attach any available lab results.
If HIV status unknown, complete the following:
 Rapid HIV test (preferred) Date/Time:
Result: __________
 Draw HIV blood test (if rapid HIV test is not available) Date/Time: ___
Call treating Concentra site immediately upon receipt of results.
Check all that apply, if known:
 High-risk sexual behavior  Injection drug user  Symptoms consistent with possible acute HIV
If HIV status known, document the following:
 HIV negative Date of test:
 HIV positive: Call treating Concentra clinician immediately with the following information:
 Most recent HIV Viral Load with date: __________ Most recent CD4 count with date: ____ ______
 Current HIV Medications
 HIV Medication resistance information if known: ________________
 Treating physician/number _______________________________
If Hepatitis B status is unknown:
 Draw Hepatitis B surface antigen (HBsAg)
 If HBsAg positive, draw Hepatitis B e antigen (HBeAg).
Call treating Concentra site immediately upon receipt of results.
If Hepatitis B status is known, document the following:
 Known positive HBsAg (infected with Hep B) Date of test:
 HBeAg negative  HBeAg positive date of test: _____
 Known negative (HBsAg Negative) date of test: __________
 Immune to hepatitis B (positive anti-HBs) date of test:
If Hepatitis C status unknown:
 Draw Anti-HCV (hepatitis C antibody):
Call treating Concentra site immediately upon receipt of results.
If Hepatitis C status is known, document the following:
 Known Hepatitis C positive: Date of test
 Known Hepatitis C status negative: Date of test
Name and role of person completing this form:
Contact Number: _
Signature:
_________________
Date:
Internal Use - Cut here
Exposed Patient Name: _________________________ ________
©2015 Concentra Operating Corp. All rights reserved.
10/08/2015
CONBBP
Date of Birth: _______________