Biological Hazards – Infectious Diseases » Written Opinion For Post-Exposure Evaluation

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.

Employer Name: 



*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).