Infection Prevention Manual

EXPOSURE CONTROL PLAN EMPLOYEE EXPOSURE INCIDENT NAME OF EMPLOYEE: ___________________________________________ JOB CATEGORY: _______________________________________________ DATE OF EXPOSURE INCIDENT:___________________________________ ROUTE OF EXPOSURE: __________________________________________ ____________________________________________________________ CIRCUMSTANCES OF EXPOSURE INCIDENT: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ SOURCE INDIVIDUAL: 1. Name: ______________________________________________ 2. Address: ___________________________________________ ___________________________________________ 3. Telephone #: ________________________________________ 4. Client _______________________________________________ 5. Other (explain)_________________________________________ _____________________________________________________________ _____________________________________________________________ 6. Known to be Infected: HBV Yes No Not Known 7. Blood Test obtained (Not needed if source individual is known to be infected.) Yes No/legally required consent cannot be obtained 8. If blood test obtained - results of the test: HBV HIV Your Agency Name (PN System)