Bloodborne Pathogens Exposure Incident Report
EMPLOYEE REPORT
Employee name
*
First Name
Last Name
Office where exposure occurred
*
Date of exposure incident
*
.
Month
.
Day
Year
Section I. Incident Details
Method of exposure:
*
Please Select
Needle stick
Cut
Splash
Other - please describe
Method of exposure:
*
Needlestick
Cut
Splash
Other - please describe below
Route of exposure:
*
Skin
Mucous membrane
Inhalation
Ingestion
Other - please describe below
Body part(s) exposed:
*
Source of exposure:
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Blood
Saliva
Other - please describe below
Brief description of circumstances that lead to exposure:
*
Section II. Employee Consent and Acknowledgment
Please read and check ONE of the following consent statements
Following exposure to blood or potentially infectious materials during the performance of my job duties, I request to have my blood collected as soon as feasible and tested for HBV/HIV serological status. I understand that I may be required to return for follow-up testing at intervals of 6 weeks, 12 weeks, and 6 months post-exposure and that if necessary, I will be required to attend these appointments.
Following exposure to blood or potentially infectious materials during the performance of my job duties, I waive my right to have my blood collected and tested for HBV/HIV serological status. I understand that the blood testing would be provided by Dental Experts, LLC at no cost to me and that the results of my blood test would remain confidential.
Employee signature
Date
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