BBP-2
BBP-2
POST_EXPOSURE MANAGEMENT RECORD
Employee Name:
Employee Name:
*
First
Last
Email
*
UIN:
*
Employee Information
*
Employee Information
Employee refuses post-exposure medical care
Employee will seek post-exposure medical care but refuses to contribute baseline blood or allow testing
Employee will seek post-exposure medical care and will contribute baseline blood to be stored at least 90 days, but refuses testing
Employee will seek post-exposure medical care and will agree to contribute blood and grants permission for HIV, Hepatitis B and Hepatitis C testing and follow-up evaluation and treatment
Source Individual Information
*
Source Individual Information
Source individual could not be identified
Source individual identified but refused to contribute blood
Source individual identified and grants permission for HIV, Hepatitis B and Hepatitis C testing
Healthcare Professional Selected:
*
I acknowledge that I have been provided with complete information and consultation regarding my exposure incident and options for post-exposure medical care
Employee Signature:
*
Date
Date
*
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MM
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DD
YYYY