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Environmental Health & Safety |
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& Follow-up Form |
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As part
of my employment with California State University, Northridge, I may
have been exposed to blood or potentially infectious materials on the
following date:
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| Injured Employee's Name: | ||
| The Route of Exposure was: |
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Exposure Incident Report Form has been completed. (COPIES FORWARDED TO EH&S AND HUMAN RESOURCES) | |
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Source individuals blood has been tested. (PROVIDED CONSENT OBTAINED) | |
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Exposed
employee has been notified of result.
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| I
further understand that, as a result of this exposure, I may require evaluation
or treatment due to the potential risk of acquiring Hepatitis B virus,
HIV, or other bloodborne infection. I was offered and encouraged to have
a confidential evaluation and follow-up and have been given the opportunity
to be vaccinated with Hepatitis B vaccine and/or Hepatitis B Immune Globulin
at no charge to myself. |
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| Please
initial here:
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| Please
check the following that apply to you: |
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I accept the Hepatitis B vaccination series. | |
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I accept the Hepatitis B Immune Globulin. | |
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I decline the Hepatitis B vaccination series. | |
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I decline the Hepatitis B Immune Globulin. | |
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I consent to baseline blood collection and HBV serological testing. | |
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I do not consent to baseline blood collection. | |
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I
consent to baseline blood collection, but do not consent to any testing
at this time. I understand that the blood sample shall be preserved for
at least 90 days. If, within 90 days of the exposure incident, I elect
to have baseline samples tested for either HBV or HIV, such testing shall
be done as soon as feasible.
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| Employee Signature: ____________________________________________________ | |
| Print Name: | Date: |
| Department: | |