Health Care Professionals
Written Opinion For Post-Exposure Evaluation*
- Employee Name:
- Date of Incident:
- Date of Office Visit:
- Health Care Facility Address:
- 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.
*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).