EXPOSURE INCIDENT CHECKLIST Information Provided to Healthcare Professional The following items must be provided to the healthcare professional who will be evaluating the exposed employee. □ □ □ The Bloodborne Pathogen Exposure Incident Report, which includes: Description of exposed employee’s duties as they relate to the exposure incident. Documentation of the route(s) of exposure and the circumstances under which the exposure occurred. Employee (Hepatitis B) vaccination status – Hepatitis B Immunization form attached. Page 1: completed by individual who has had an exposure incident. Clinic Supervisor must sign and the completed form returned to the Clinical Affairs Office BEFORE lab work. (Original is kept by Clinical Affairs/ copy of form is sent to Healthcare Professional. Page 2: Source Information - completed by source individual (usually patient) and Clinic Supervisor. Patient must indicate consent or decline medical testing. Original is kept by Clinical Affairs/copy of form is sent to Healthcare Professional. Declination of Post-Exposure Evaluation and Follow-up. Form to be completed by staff/student/faculty if they choose to decline post-exposure testing and follow-up treatment. The University of Louisville Health Services Office is the Healthcare Provider for medical consultation, testing and evaluation. The HSC Health Services maintains a copy of the Bloodborne Pathogens Standard and ULSD’s Guidelines and does not require an additional copy be sent. ULSD will send other relevant medical records to the HSC Health Services when appropriate. The Healthcare professional must provide ULSD with: □ Healthcare Professional’s Written Opinion: to be completed by Healthcare Provider and sent back to Clinical Affairs within 15 days of the evaluation. PACKET NO. Packet given to exposed individual by: ______________________ __________ Date: ________ Name of exposed individual: _____________________________________________ Department/clinic: _____________________________________________________ Comments: __________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ EXPOSURE PACKET – ULSD Exhibit A-1 5/19/06 Bloodborne Pathogen Exposure Incident Report This form must be completed by any faculty, staff or student who has a needlestick or puncture wound OR contamination of any open wound or mucous membrane by blood or saliva. Any faculty/staff/student who suffers an exposure incident must immediately report the incident to the appropriate supervisor and the Clinical Affairs Office. Complete Page 1 of the Bloodborne Pathogen Exposure Incident Report as soon as feasible. The clinical supervisor is responsible for completing Page 2 and ensuring that the plan for post-exposure evaluation and follow-up is adhered to. Exposed Individual: Social Security #: Check One: Patient Student Faculty Resident Staff Department And/or Clinic: Has exposed individual received the HBV vaccination series? Incident Description Date of incident: Time of incident: Potentially Infectious Material(s) involved: Blood Saliva Other ___________________ No Yes (see page 5) Exact Location: Patient Treatment Area Clean-Up Sterilization Lab Type of Incident (route of exposure): Instrument cut Instrument stick Splash Other __________________________________ _________________________________________ Describe your duties as they relate to the exposure incident (include procedure being performed): Describe the circumstances under which exposure occurred: Which personal protective equipment was being used? (i.e. gloves, etc.) I verify that the information above is correct and accurately describes the exposure incident in which I was involved. EXPOSED INDIVIDUAL’S SIGNATURE ____________________________________ Name/patient # EXPOSURE PACKET – ULSD DATE Is Source Individual known? Source Individual’s Information completed? (page 2) Exhibit A-2 Yes No Yes No 5/19/06 Bloodborne Pathogen Exposure Incident Report – Source Information TO BE COMPLETED BY CLINIC SUPERVISOR Source is: Known Unknown Name of Source: ___________________________________ Date of Birth: ___________ Documentation from Health History/Dental Record: Previously diagnosed HIV positive? No Yes – Date: ___________________ Previously diagnosed HBV positive? No Yes – Date: ___________________ Previously diagnosed HCV positive? No Yes – Date: ___________________ □ I Consent to Medical Testing. I voluntarily consent to diagnostic testing for myself, or my child, in order to determine the possible presence of bloodborne infectious or communicable diseases. I understand that the Healthcare Professional responsible for testing will ask me to sign an authorization so the results of the test can be disclosed to the exposed individual’s physician. This testing will be performed at no cost to me. PATIENT SIGNATURE/LEGAL REPRESENTATIVE □ □ DATE Source Patient was referred to ___________________________________________ (Physician) for HIV, HBV, and HCV blood testing. I Do not Consent to Medical Testing. I do not consent to testing for possible bloodborne infectious or communicable diseases. PATIENT SIGNATURE/LEGAL REPRESENTATIVE DATE I certify that the above information regarding the source individual has been documented and I will forward a copy of this form and other necessary records or documents to the above-named healthcare professional for the evaluation of the exposed employee. Signature – Clinical Supervisor EXPOSURE PACKET – ULSD DATE Exhibit A-3 5/19/06 TO BE COMPLETED BY INDIVIDUAL WITH EXPOSURE INCIDENT □ Staff □ Student/Resident □ Faculty □ Other: ___________________________ CONFIDENTIAL Informed REFUSAL of Post Exposure Medical Evaluation I, __________________________________________, am employed by the University of Louisville School of Dentistry, as a _____________________________________________. My employer has provided training to me regarding exposure control for bloodborne pathogens and the risk of disease transmission in the dental clinics. On ________________________, 20___, I was involved in an exposure incident when I: (DESCRIBE DETAILS OF NEEDLESTICK/INCIDENT, ETC.) My employer has offered to provide post exposure medical evaluation and follow-up for me in order to assure that I have full knowledge of whether I have been exposed to or contracted an infectious disease from this incident. However, I, of my own free will and volition, and despite my employer’s offer, have elected NOT to have a medical evaluation. I have personal reasons for making this decision. Witness Signature of Employee Name (please print) Department/Clinic Note: This record will be maintained for the duration of employment plus 30 years. Medical records of employees who have worked for less than one year need not be retained beyond the term of employment if the records are provided to the employee upon the termination of their employment. EXPOSURE PACKET – ULSD Exhibit A-4 5/19/06 CONFIDENTIAL Post Exposure Evaluation and Follow-up Healthcare Professional’s Written Opinion For __________________________________________________ NAME OF EMPLOYEE/RESIDENT/STUDENT To the healthcare professional: OSHA requires the healthcare professional who provides post-exposure evaluation and follow-up services to an employee to provide a written opinion in the form provided below. Please complete this form and return it to the employee at the time services are rendered. Thank you for your cooperation. I hereby certify that on ___________________ (date) I evaluated the employee whose name appears above and informed the employee of the results of the evaluation; and any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment. Healthcare professional recommends HBV vaccination? ____ Yes ____ No NOTE: ALL OTHER FINDINGS OR DIAGNOSIS ARE CONFIDENTIAL AND SHOULD NOT BE INCLUDED IN THIS WRITTEN REPORT. SIGNATURE OF HEALTHCARE PROFESSIONAL DATE Note: ULSD will maintain this record for the duration of employment plus 30 years. A copy of the Healthcare Professional’s Written Opinion will be provided to the employee within 15 days after the evaluation is completed by the Healthcare Professional. EXPOSURE PACKET – ULSD Exhibit A-5 5/19/06