Exposure Incident Packet- WCMP

CSRMA: Workers’ Compensation Management Program

EXPOSURE INCIDENT PACKET

INSTRUCTIONS

This packet must be completed when an Employee has an Exposure Incident. An Exposure Incident has occurred when an Employee’s eye, mouth, mucous membrane, or other non-intact skin, has come in contact with blood or other potentially infectious material as the result of a needle stick, bite, cut, abrasion, etc.

Supervisor:

q Complete and sign the Exposure Incident Report with the Employee.

q Complete Information Provided to Healthcare Professional form.

q If the Exposure Incident was the result of a sharps injury, complete the Sharps Injury Log with the Employee. (This form can be completed immediately or at a later date within 14 working days of the report of the incident.)

q If source individual can be identified and is receiving treatment at a medical facility, complete the Source Individual Report Form (leave Results of Medical Review space blank).

If source individual is not currently receiving medical care, complete the Source Individual Memo and Source Individual Testing Request.

q You will need 3 copies of the Exposure Incident Report and 2 copies of each of the other forms. Discard unused forms. Place forms in the appropriate envelopes according to each envelope’s list of contents.

q Give the Employee Envelope to the Employee to retain for records.

q Give the Clinic Envelope to the Employee and direct him/her to the designated medical clinic.

q Fax the Source Individual Report Form to the medical facility where the source individual is receiving medical care,

Mail the Source Individual Envelope to the source individual if individual is not currently receiving medical care

q Send the Safety Officer Envelope to the Safety Officer (Check box on envelope if Sharps Injury Log is enclosed.)

CSRMA: Workers’ Compensation Management Program SUP

EXPOSURE INCIDENT PACKET COMPLETE

EXPOSURE INCIDENT REPORT

EMPLOYEE: / SOC. SEC. #:
AGENCY: / DEPARTMENT:
DATE OF EXPOSURE INCIDENT: / LOCATION:
DESCRIPTION OF INCIDENT: (attach additional page if necessary)
NATURE OF ENTRY/EXPOSURE: (e.g. puncture, cut, etc.):
ROUTE OF ENTRY/EXPOSURE: (e.g. non-intact skin, mucous membrane, etc.):
INSTRUMENT OF ENTRY/EXPOSURE: (e.g. needle, knife, etc.):
ACTION REQUIRED TO PREVENT REOCCURRENCE:
SOURCE INDIVIDUAL
Is Source Individual Identifiable? YES NO / Is Source Individual receiving medical treatment? YES NO
Individual’s Name: / Medical Facility Name:
Individual’s Address: / Fax Number:
Did Source Individual consent to testing? YES NO
Date of test: / Name of laboratory/physician:
Results of source person testing made available to Employee? Yes No Results not yet available
EXPOSED EMPLOYEE
Consents to collection of blood for testing?
Yes No / Consents to testing for HIV?
Yes No / Consents to testing for HBV?
Yes No / Consents to testing for HCV?
Yes No
SUPERVISOR
PRINT: / SIGN: / DATE:
EMPLOYEE
PRINT: / SIGN: / DATE:

Original: Safety Officer Envelope

Copy: Employee Envelope

Clinic Envelope

INFORMATION PROVIDED TO

HEALTHCARE PROFESSIONAL

Re: EXPOSURE INCIDENT

TO: Agency Medical Clinic

FROM: CSRMA Agency

RE: EMPLOYEE NAME:

SOC. SEC. NUMBER:

Please evaluate this Employee for exposure to blood or other potential infectious materials (OPIM). The OSHA Bloodborne Standard requires that I provide you with the following regulations and information.

“Healthcare Professional’s Written Opinion.

(i) The employer shall obtain and provide the employee with a copy of the evaluating healthcare professional’s written opinion within 15 days of the completion of the evaluation.

(ii) The healthcare professional’s written opinion for post-exposure evaluation and follow-up shall be limited to the following information:

(A) That the employee has been informed of the results of the evaluation; and

(B) That the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which required further evaluation or treatment.

(iii) All other findings or diagnoses shall remain confidential and shall not be included in the written report.”

Attached for your information is the Exposure Incident Report. Please provide me with your written opinion as required by this OSHA regulation.

Original: Agency Safety Officer

Copy: Clinic Envelope

CSRMA: Workers’ Compensation Management Program SUP & EE

EXPOSURE INCIDENT PACKET COMPLETE

SHARPS INJURY LOG

The Supervisor and Employee must complete this form within 14 working days of the report of an Exposure Incident that was the result of a sharps injury.

DEPARTMENT: / TODAY’S DATE:
DATE OF EXPOSURE INCIDENT: / TIME OF EXPOSURE INCIDENT:
DATE OF EXPOSURE INCIDENT REPORT: / EXPOSURE INCIDENT REPORT WRITTEN BY:
TYPE & BRAND OF SHARP INVOLVED:
DESCRIPTION OF EXPOSURE INCIDENT
JOB TITLE OF EXPOSED EMPLOYEE:
WORK AREA WHERE INCIDENT OCCURRED:
ACTIVITY BEING PERFORMED BY EMPLOYEE AT TIME OF EXPOSURE:
HOW THE INCIDENT OCCURRED:
BODY PART(S) INVOLVED:
DID THE DEVICE INVOLVED HAVE ENGINEERED SHARPS INJURY PROTECTION? / YES NO Not Applicable
IF YES / WAS THE PROTECTIVE MECHANISM ACTIVATED?
YES NO
COMMENTS:
DID THE INCIDENT OCCUR BEFORE, DURING OR AFTER THE MECHANISM WAS ACTIVATED?
BEFORE DURING AFTER
COMMENTS:
IF NO / DOES THE EXPOSED EMPLOYEE BELIEVE THAT A PROTECTIVE MECHANISM COULD HAVE PREVENTED THE INJURY?
YES NO
IF YES, DESCRIBE EMPLOYEE’S OPINION:
DOES THE EXPOSED EMPLOYEE BELIEVE THAT ANY CONTROLS (E.G. ENGINEERING, ADMINISTATIVE, OR WORK PRACTICE) COULD HAVE PREVENTED THE INCIDENT?
YES NO
IF YES, DESCRIBE EMPLOYEE’S OPINION:
SUPERVISOR’S COMMENTS REGARDING THE INCIDENT:
ADDITIONAL EMPLOYEE COMMENTS:
SUPERVISOR NAME: / SIGNATURE: / DATE:
EMPLOYEE NAME: / SIGNATURE: / DATE:

Original: Safety Officer Envelope

Copy: Employee Envelope

Clinic Envelope

CSRMA: Workers’ Compensation Management Program SUP & DR

EXPOSURE INCIDENT PACKET COMPLETE

SOURCE INDIVIDUAL REPORT FORM

(Use this form if the Source Individual is currently receiving medical care.

Discard form if not used.)

DATE:
FAX TO: / FROM:
MEDICAL FACILITY: / AGENCY:
PHONE NUMBER: / PHONE NUMBER:
FAX NUMBER: / FAX NUMBER:

The following individual has been involved in an exposure incident with one of our Agency Employees. In accordance with the Ryan White Act, I am requesting that your facility determine whether or not the source individual has an infectious disease. Please complete the bottom portion of this form (Results of Medical Review) and fax it back to me within 48 hours.

EMPLOYEE IDENTIFICATION NUMBER:
DATE OF SUSPECTED/KNOWN EXPOSURE: / TIME:
LOCATION OF INCIDENT:
SOURCE INDIVIDUAL NAME (please delete with return results):
CIRCUMSTANCES OF EXPOSURE:
RESULTS OF MEDICAL REVIEW (to be completed by Medical Facility):

Original: Fax to Source Individual Medical Facility

Copy: Safety Officer Envelope

CSRMA: Workers’ Compensation Management Program SUP

EXPOSURE INCIDENT PACKET COMPLETE

SOURCE INDIVIDUAL MEMO

(Send this memo if the Source Individual is not currently receiving medical care.

Discard form if not used.)

TO:

SOURCE INDIVIDUAL

FROM: ______

AGENCY SAFETY OFFICER

______

AGENCY

DATE:

Re: Possible Exposure Incident

I am writing to inform you that an incident occurred that may have resulted in an exposure to one of our Employees involving your blood or other potentially infectious materials on the date of .

By law, and as a responsible employer, I am requesting that you consent to testing to determine your HBV, HCV and HIV infectiousness. The results of such testing, which shall remain confidential between you and the exposed Employee, can substantially reduce the anxiety of the Employee regarding the exposure incident.

Please carefully consider the consequences for the Employee if you refuse testing. If you decide to consent to testing, please take the enclosed form to the clinic indicated. The Agency will, of course, pay all expenses associated with the testing. If you have any questions regarding this incident or the testing, please contact me at ______.

Thank you for your prompt consideration of this matter.

Original: Source Individual Envelope

Copy: Safety Officer Envelope

SOURCE INDIVIDUAL TESTING REQUEST

(Send this form with the Source Individual Memo if the individual is not currently receiving medical care.

Discard form if not used.)

TO:

AGENCY MEDICAL CLINIC

FROM: ______

AGENCY SAFETY OFFICER

______

AGENCY

RE: Request for Testing of Exposure Incident Source Individual

has been identified as the source individual in an Exposure

Source Individual’s Name

Incident that occurred on . The Employee who was involved in the incident is .

Employee’s Name

Please perform testing to determine whether or not the Source Individual has a communicable disease. The results of this test should be made known confidentially to ,

Safety Officer

At . All cost for this testing will be paid for

Agency Name and Address

by . Submit billing requests to me at the same

Name of Agency

address. If you have any questions, please contact me at .

Telephone Number

Original: Source Individual Envelope

Copy: Safety Officer Envelope

CSRMA: Workers’ Compensation Management Program

EXPOSURE INCIDENT PACKET

EMPLOYEE ENVELOPE

You have been involved in an Exposure Incident. The following documents are enclosed:

ü Exposure Incident Report

Sharps Injury Log (Supervisor check box if this form is enclosed)

Retain document(s) for your records. If you have any questions regarding this incident, contact your Supervisor or the Safety Officer at ______.

CLINIC ENVELOPE

One of our Employees has been involved in an Exposure Incident. Please read the materials enclosed and take action as requested. The following documents are enclosed:

ü Exposure Incident Report

ü Information Provided to Healthcare Professional Re: Exposure Incident

If you have any questions regarding this incident of the follow up reporting procedures, please contact the Safety Officer at ______.

SOURCE INDIVIDUAL

STREET ADDRESS

CITY/STATE/ZIP CODE

enclosed: SOURCE INDIVIDUAL MEMO Print on #10 Envelope

SOURCE INDIVIDUAL TESTING REQUEST With Agency Return Address

CSRMA: Workers’ Compensation Management Program

EXPOSURE INCIDENT PACKET

SAFETY OFFICER ENVELOPE

One of our Department’s Employees has been involved in an Exposure Incident. The following documents are enclosed:

ü Exposure Incident Report

ü Information Provided to Healthcare Professional Re: Exposure Incident

Sharps Injury Log (Supervisor check box if this form is enclosed)

Source Individual Report Form (Supervisor check box if this form is enclosed)

Source Individual Memo (Supervisor check box if this form is enclosed)

Source Individual Testing Request (Supervisor check box if this form is enclosed)