Download Risk assessment of source of blood exposure

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