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ASSESSMENT concerning risk of bloodborne pathogen transmission 1 Sep 2011 RISK ASSESSMENT CONCERNING THE SOURCE OF BLOOD CONTAMINATION This is a routine questionnaire to assess the risk of bloodborne pathogen transmission in connection with a needlestick accident. Please answer the following questions even though they are of a very personal nature. The information you provide will be given to health care staff to allow the planning of further measures. Source of blood contamination Name Identity code Have you been abroad for a long period of time? Yes In which country/countries? For what purpose? Period when abroad No Have you, any of your family members or your sex partner had a hepatitis B or C infection or a positive result in an HIV test? Yes No Have you or your sex partner ever used an injected drug or narcotic medicines, even just once? Yes No Have you or your sex partner had unprotected sexual contact with foreign persons or prostitutes during the past 12 months, as far as you know? Yes No Have you or your sex partner received a blood transfusion (e.g. during surgery) during the past 12 months, as far as you know? Yes No Samples will be taken for hepatitis B, hepatitis C and HIV testing. date place signature I do not wish to have samples taken. date place signature
