Appendix C - Medical Evaluation and Follow-Up - Bloodborne Pathogen Policy

Appendix C - Medical Evaluation and Follow-Up 

Employee Name: __________________________________________ 

Date of Exposure: _________________  

To be completed by Health Care Provider: 

Blood collected and Tested:  _______HBV ______HIV ______Declined Blood Testing 

Hepatitis B  ________ No prior Hepatitis B vaccination

________ HBIG (Hepatitis B Immune Globulin) given

________ HBV vaccinated - received 3 doses prior 

________ HBV series started

 HIV              ________ Risk counseling offered

Comments:___________________________________________________________

____________________________________________________________________

Post Exposure Medical Evaluation Completed by:____________________________ 

Print Name: __________________________________________________________ 

Signature: ___________________________________________________________

Date: _____________________