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