Download Attachment B - George Mason University

GEORGE MASON UNIVERSITY
BLOOD BORNE PATHOGEN EXPOSURE INCIDENT
CONFIDENTIAL
(Employee Name)
(Social Security Number)
(Home Address)
(Investigator's Name)
Healthcare Professional's Name)
Healthcare Professional's Name) (Address)
(Telephone)
PART 1. EMPLOYER'S RESPONSIBILITIES TO HEALTHCARE PROFESSIONAL EVALUATING THE
EMPLOYEE:
Provided copy of Title 29 Code of Federal Regulations. section 1910.1030.
Provided all medical records relevant to the appropriate treatment of employee including
vaccination status as maintained by the employer.
Date(s), time(s), location(s), & witness(es) as they relate to exposure incident:
Description of exposed employees duties as they relate to exposure incident:
Result of source individual's blood testing (if available and releasable):
Circumstances and documentation of route(s) of exposure under which exposure occurred
(Use reverse side if required)
Part 2: Healthcare Professional's Written Opinion
Date Exam Completed:
Employee has been informed of results of the evaluation.
Employee has been informed about any medical conditions resulting
from exposure to blood or other potentially infectious materials which
require further evaluation or treatment.
Hepatitis vaccine is indicated for this employee.
Employee has received Hepatitis B vaccination.
Hepatitis B inoculation dates are scheduled as follows:
yes [
]
yes [ ]
No [
]
No [
yes [
yes [
]
]
No [
No [
]
]
]
(Licensed Healthcare Professional s Signature)
PART 3. DECLINATION STATEMENT (when appropriate):
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of
acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the HBV vaccine, at
no charge to myself. However, I decline the HBV vaccine at this time. I understand that by declining this vaccine, I
continue to be at risk of acquiring HBV, a serious disease. If in the future I continue to have occupational exposure to
blood or other potentially infectious materials and I want to be vaccinated against HBV, I can receive the vaccination
series at no charge to me.
PART 4. HEALTHCARE PROFESSIONALS RESPONSIBLE FOR THE EMPLOYEE'S HBV IMMUNIZATION:
FIRST INOCULATION (see note at bottom):
Provided copy of Title 29 Code of Federal Regulations, section 1910.1030.
Healthcare Professional's Name)
yes [
] no [
]
(Date)
SECOND INOCULATION (see note at bottom):
Healthcare Professional's Signature
(Date)
THIRD INOCULATION (see note at bottom):
(Healthcare Professional's Signature)
(Date)
PART 5. ACTIONS TAKEN AS A RESULT OF INCIDENT:
Note: If employee declines HBV vaccination he/she is to complete the Declination Statement in Part 4. If the employee has consented to a baseline blood collection,
but does not give consent for HIV serologic testing at this time, the sample shall be preserved for ninety days. All other findings/diagnosis shall remain confidential and
not be included in this report. A copy of the healthcare professional's written opinion shall be provided to the employee within 15 days of completion of exam. This
report will not be disclosed or reported without the employee's express written consent to any person outside the workplace except as required by Title 29 Code of
Federal Regulations, section 1910.1030 or as required by law.