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Health Care Professionals

Written Opinion For Post-Exposure Evaluation*
  1. Employee Name:_____________________________________________
  2. Date of Incident:_____________________________________________
  3. Date of Office Visit:__________________________________________
  4. Health Care Facility Address:__________________________________
  5. Health Care Facility Telephone:________________________________
As required under the Bloodborne Pathogen Standard:

______ The employee named above has been informed of the results of the post-exposure health evaluation.

______ The employee named above has been told about any health conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment.

______ Hepatitis B vaccination is ____ is not ____ indicated.

Signature of health care provider:_______________________ Date: ________

Printed or typed name of health care provider:___________________________

This form is to be returned to the employer, and a copy provided to the employee within 15 days.

Employer Name:______________________________



*This form was taken from: Model Exposure Control Plan for Home Care: A Guide for Hospice/Home Agencies on the Bloodborne Pathogens Standards. OSHA Office of Occupational Nursing, (1994).