APPENDIX  F

POST-EXPOSURE EVALUATION AND FOLLOW-UP CHECKLIST

The following steps must be taken, and information transmitted, in the case of an employee's exposure to bloodborne pathogens:

ACTIVITY

COMPLETION DATE
  • Employee furnished with documentation regarding exposure incident.
____________________
  • Source individual identified.

_____________________________ Name

 ____________________
  • Source individual's blood tested and results given to exposed employee.

Consent has not been obtained.

 ____________________
  • Exposed employee's blood collected and tested.
 ____________________
  • Appointment arranged for employee with health care professional.

________________________ Professional's Name

 ____________________
  • Documentation forwarded to healthcare professional.
__________ Bloodborne Pathogens Standard
__________ Description of exposed employee's duties.
__________ Description of exposure incident, including routes of exposure.
__________ Result of source individual's blood testing.
__________ Employee's medical records.