Infection Prevention Manual

EXPOSURE CONTROL PLAN REFERRAL FOR EVALUATION 1. Employee referred for evaluation, consultation, serologic testing, treatment, if necessary and follow up as applicable. Name of evaluating health care professional/institution Address: 2. Employee sent a copy of the evaluator's written opinion. 3. Evaluator sent: copy of OSHA regulation 29 CPR Part 1910.1030 Occupational Exposure to Bloodborne Pathogens. copy of this form that includes: a) a description of the exposed employee's duties as they relate to the exposure incident, b) documentation of the route(s) of exposure and circumstances under which exposure occurred, c) results of the source individual's blood testing, if available. copy of employee's Hepatitis B vaccination status copy of any other medical records relevant to the appropriate treatment of the employee. Employee Exposure Incident Healthcare Professional's Written Opinion 1. Written opinion obtained (within 15 days) from the evaluating healthcare professional indicating: whether hepatitis B vaccine is indicated. did employee receive hepatitis B vaccine. That the employee has been told about any medical conditions resulting from exposure to blood or any potentially infectious materials which require further evaluation or treatment. ____________________________________________________ Administrator Signature _____________ Date Employees with a known or suspected infectious and/or contagious disease shall be restricted from providing patient care. A statement may be required from the employee's physician stating that the employee is free from contagious diseases and is able to return to work. Occurrences such as, but not limited to the following, shall be reported to the employee's supervisor for documentation and investigation prior to the employee providing patient care: Upper respiratory infections Temperatures greater than 101 degrees F Wounds or skin infections Conjunctivitis Diseases from the list of reportable diseases Your Agency Name (PN System)