Infection Prevention Manual

EXPOSURE CONTROL PLAN POST OCCUPATIONAL EXPOSURE TO BLOODBORNE PATHOGEN EVALUATION Name of evaluating healthcare professional/agency ________________________________ _________________________________________________________________________ Address:__________________________________________________________________ Name of Employee:_________________________________________________________ The above-named employee has been referred to you for postoccupational exposure to bloodborne pathogen evaluation. A copy of the Employee Exposure Incident as well as OSHA regulation 29 CFR Part 1910.1030 has been given to you. This OSHA regulation contains specific instructions about what is required (tests, prophylaxis, counseling, etc.) in the evaluation. In addition, OSHA regulations require that we receive a written opinion from you within 15 days of the completion of the evaluation. This written opinion must include specific information. Please complete the required information below and return this form to us within the required 15 days in the self-addressed, stamped envelope provided. Thank you. 1. Is Hepatitis B vaccination indicated for this employee? _____yes _____no 2. Has the employee received the Hepatitis B vaccine? _____yes _____no 3. Has the employee been informed of the results of the evaluation? ___yes ___no 4. Has the employee been told about any medical conditions resulting from the exposure to blood or other potentially infectious material which would require further evaluation or treatment? ______yes _____no All other findings or diagnoses will remain confidential and should not be included in this written report. _____________________________________ Signature of healthcare professional Your Agency Name (PN System)