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: _____________________