Incident Reports

Table of Contents
Function/Purpose......................................................................................................................... 1
When to Report............................................................................................................................ 1
OSHA Recordkeeping Requirements...........................................................................................1
Who Should Report...................................................................................................................... 2
Emploee Responsi!ilit.............................................................................................................. 2
Super"isor Responsi!ilit............................................................................................................. 2
#ips $or Reporting %ncidents......................................................................................................... &
%nstructions $or 'ompletion o$ Form.............................................................................................&
%ncident/'ompl(int Report........................................................................................................... )
*(!or(tor %ncident Report.......................................................................................................... +
Post,E-posure %ncident Source %ndi"idu(l 'onsent Form.............................................................
Post,E-posure %ncident E-posed Emploee 'onsent Form........................................................./
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INCIDENT REPORTS
Function/Purpose
An incident report is not p(rt o$ the p(tient4s ch(rt3 !ut it m( !e used l(ter in litig(tion. A report
h(s t5o $unctions6
1. %t in$orms the (dministr(tion o$ the incident so m(n(gement c(n pre"ent
simil(r incidents in the $uture.
2. %t (lerts (dministr(tion (nd the $(cilit4s insur(nce comp(n to ( potenti(l
cl(im (nd the need $or in"estig(tion.
Regul(tions issued under OSHA require (ll emploers 5ith more th(n ten emploees (t (n
time during the pre"ious c(lend(r e(r to m(int(in records o$ record(!le occup(tion(l in7uries
(nd illnesses.
When to Report
%ncidents th(t must !e reported (nd documented include6
1. E-posure %ncidents6 skin3 ee3 mucous mem!r(ne or p(rent(l cont(ct 5ith !lood or
other potenti(ll in$ectious m(teri(ls th(t m( result $rom the per$orm(nce o$ (n
emploee4s duties.
2. Accident3 %n7ur6 p(tient3 "isitor3 emploee slips or $(lls3 or other incident3 5hich results
or m( result in in7ur.
&. E"ent3 8eh("iors3 or Actions6 incidents th(t (re unusu(l3 contr(r to (genc polic or
procedure or 5hich m( result in in7ur.
). 2(ccine Ad"erse E"ent Reporting Sstem6 re(ction to "(ccine (dministered (t (genc
9use 2AERS $orm3 instructions (nd s(mple in %mmuni:(tion section;.
<. =edic(tion re(ction6 re(ction to (n drug (dministered (t or pro"ided ! he(lth
dep(rtment. 'omplete Ad"erse >rug Re(ction Form. For more in$orm(tion3
c(ll 1,.00,&&2,10...
+. Propert d(m(ge or missing (rticles.
?. Administr(tion o$ 5rong medic(tion or "(ccine.
.. %mproper (dministr(tion o$ medic(tion or "(ccine.
OSH Record!eepin" Re#uire$ents
OSHA &00 *og,record(!le (nd nonrecord(!le in7uries (re distinguished ! the tre(tment
pro"ided@ i.e.3 i$ the in7ur required medic(l tre(tment3 it is record(!le@ i$ onl $irst (id 5(s
required3 it is not required3 it is not record(!le. Ho5e"er3 medic(l tre(tment is onl one o$
se"er(l criteri( $or determining record(!ilit. Reg(rdless o$ tre(tment3 i$ the in7ur in"ol"ed loss
o$ consciousness3 restriction o$ 5ork or motion3 tr(ns$er to (nother 7o! or termin(tion o$
emploment3 the in7ur is record(!le. An e-pl(n(tion3 5ith e-(mples3 is included on the
!(ckside o$ the OSHA &00 Form.
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Who Should Report
Onl people 5ho 5itness the incident should $ill out (nd sign the incident report. E(ch
5itness should $ile ( sep(r(te report. Once the report is $iled3 the nursing super"isor3
dep(rtment he(ds3 (dministr(tion3 the $(cilit4s (ttorne3 (nd the insur(nce comp(n m(
re"ie5 it.
8ec(use incident reports 5ill !e re(d ! m(n people (nd m( e"en turn up in court3 ou
must $ollo5 strict guidelines 5hen completing them. %$ (n incident report $orm does not
le("e enough sp(ce to $ull descri!e (n incident3 (tt(ch (n (ddition(l p(ge o$ comments.
>ocument the incident (s it occurred in the p(tient4s medic(l record3 A%ncident Report
'ompletedB should ne"er (ppe(r in the p(tient4s record. #he incident report should ne"er
!e re$erred to in (n 5( in the medic(l record.
E$plo%ee Responsibilit%
All emploees (re responsi!le $or prep(ring (n incident report (s soon (s possi!le (nd
reporting immedi(tel to their super"isor or in the super"isors (!sence report to the
(dministr(tion (n incident or in7ur including ne(r misses. Recommend(tions (nd
(ppropri(te ch(nges sh(ll !e discussed 5ith the super"isor (nd necess(r corrections
implemented to pre"ent $urther (ccidents.
Super&isor Responsibilit%
Cpon recei"ing ( report o$ (n incident3 5ritten or or(l3 the super"isor sh(ll conduct (n
in"estig(tion. Follo5ing the in"estig(tion3 super"isors (re to re"ie5 (nd complete the
%ncident Report (nd initi(te Worker 'ompens(tion Report i$ indic(ted $or the *H>s
insur(nce c(rrier. #he super"isor sh(ll t(ke (ction to implement correcti"e me(sures
immedi(tel 5hen the in"estig(tion re"e(ls such (ctions (re necess(r.
#he super"isor sh(ll pro"ide ( cop o$ the %ncident Report (nd the Worker4s 'ompens(tion
Report 9i$ necess(r; to the *H>s S($et O$$icer 5ithin $i"e 5orking d(s o$ the (ccident.
Reports o$ (ll incidents (nd ne(r misses should !e discussed during meetings 5ith
emploees o$ the 5ork unit to pre"ent pro!lems o$ the s(me n(ture in the $uture.
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Tips for Reportin" Incidents'
1. %nclude essenti(l in$orm(tion3 such (s identit o$ the person in"ol"ed in the incident3 the
e-(ct time (nd pl(ce o$ the incident (nd the n(me o$ the doctor ou noti$ied.
2. >ocument (n unusu(l occurrences th(t ou 5itnessed.
&. Record the e"ents (nd the consequences $or the p(tient in enough det(il th(t
(dministr(tors c(n decide 5hether or not to in"estig(te $urther.
). Write o!7ecti"el3 ("oiding opinions3 7udgments3 conclusions3 or (ssumptions (!out 5ho
or 5h(t c(used the incident. #ell our opinions to our super"isor l(ter.
<. >escri!e onl 5h(t ou s(5 (nd he(rd (nd the (ctions ou took to pro"ide c(re (t the
scene. Cnless ou s(5 ( p(tient $(ll3 5rite A$ound p(tient ling on the $loorB.
+. >o not (dmit th(t ou (re (t $(ult or !l(me someone else. Steer cle(r o$ st(tements like
A!etter st($$ing 5ould h("e pre"ented this incidentB.
?. >o not o$$er suggestions (!out ho5 to pre"ent the incident $rom h(ppening (g(in.
.. >o not include det(iled st(tements $rom 5itnesses (nd descriptions o$ remedi(l (ction@
these (re norm(ll p(rt o$ (n in"estig(ti"e $ollo5,up.
/. >o not put the report in the medic(l record. Send it to the person design(ted to re"ie5 it
(ccording to our $(cilit4s polic.
From the !ook Charting Made Incredibly Easy Springhouse 'orpor(tion.
#he $ollo5ing (re SA=P*E copies o$ A%ncident/'ompl(int ReportB3 A*(!or(tor %ncident ReportB3
Emploee 'onsent $or 8lood #esting,Post E-posureB3 (nd AP(tient 'onsent $or 8lood #esting,
Post E-posureB. Some (gencies m( use incident reports supplied or recommended ! their
insur(nce c(rrier.
INSTR(CTIONS FOR CO)P*ETION OF FOR)
#he 'ompl(int/%ncident Form is to !e used to document the $ollo5ing6
1. An tpe o$ (ccident3 "ehicle or other5ise3 5hich m( or m( not in"ol"e in7uries.
2. P(tient 1 pro"ider con$licts.
&. Emploee con$licts.
). 'ompl(ints.
When reporting ( compl(int/incident $ollo5 these steps6
1. 'omplete the $orm (nd o!t(in (ppropri(te sign(tures.
2. Su!mit the origin(l $orm to the district o$$ice 5ithin $i"e 5orking d(s.
&. %$ ( cop is kept (t the loc(l o$$ice3 it must !e $iled in ( locked c(!inet.
%$ (n $urther (ssist(nce is needed3 ple(se cont(ct our discipline director.
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INCIDENT/CO)P*INT REPORT
E=P*ODEE6 Return this 'O=P*E#E> FOR= to our SCPER2%SOR (s soon (s possi!le.
E(me o$ Person %n"ol"ed6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
Address6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF 'it6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
Phone Eum!er6 FFFFFFFFFFFFFFFFFFFFF Age6 FFFFFFFF >O86 FFFFFFFFFFFFF Se-6 = FFFF F FFFFF
SSG6 FFFFFFFFFFFFFFFFFFFFFFFFF >(te o$ %ncident6 FFFFFFFFFFFFF #ime6 FFFFFF (m/pm
E-(ct *oc(tion o$ %ncident6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
'heck #pe o$ Accident6 'heck6
'leric(l/>(t( Entr FFFFF P(tient
'ommunic(tions FFFFF Emploee
#esting Process FFFFF 2isitor
Result reporting FFFFF 2olunteer
S($et FFFFF Other
=edic(l >e"ice F(ilure
Polic/Procedur(l 2iol(tions
Ad"erse >rug Re(ction
2ehicle Accident
Eeedlestick
E-posure to H(:(rdous Su!st(nce
=edic(tion Error 9Wrong6 Route3 >os(ge3 =edic(tion3 Schedule;
E)P*O+EE' %n"ol"ed FFFFF es FFFFF no
Were the doing their regul(r 7o! duties6 FFFFF es FFFFF no O!ser"ed ! emploee es
Hire >(te6 FFFFFFFFFFFF =(rit(l St(tus6 FFFFFFFFFFFF Situ(tion o!ser"ed onl ! emploee es
Emploee 'l(ssi$ic(tion6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
Protecti"e Equipment !eing used6 FFFFF es FFFFF no
%$ not used3 Wh6
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
>escription o$ %ncident/'ompl(int 9Who3 Wh(t3 Where3 Ho53 Wh3 %nclude sequence o$ e"ents3 personnel
in"ol"ed3 !od p(rt in7ured3 re(son incident occurred; 9%$ medic(tion error include !r(nd n(me3
m(nu$(cturer3 dos(ge; 9Cse (ddition(l $orm i$ necess(r;
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
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Actions #(ken ! St($$ =em!ers6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
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,
Witness E(me6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF Phone Eum!er6 FFFFFFFFFFFFFFFFFFFFFFFFF
Address6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
Witness E(me6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF Phone Eum!er6 FFFFFFFFFFFFFFFFFFFFFFF
Address6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
)EDIC* FO**OW-(P' W(s =edic(l Attention Sought6 FFFFF es FFFFF no
#re(tment Re$used6 FFFFF es FFFFF no First #re(tment >(te6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFF
#re(ting Phsici(n6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF Phone Eum!er6 FFFFFFFFFFFFFFFFFFFF
Address6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
First >( O$$ Work6 FFFFFFFFFFFFFFFFFFFFFFFFF Return to Work >(te6 FFFFFFFFFFFFFFFFFFFFFFF
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>uties Restricted6 FFFFF es FFFFF no E-pl(in6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
INCIDENT/CO)P*INT REPORT
%ncident Reported 86 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te6 FFFFFFFFFFFFFFFFFFFFFFFF
Super"isor Eoti$ied6 FFFFF es FFFFF no >(te6 FFFFFFFFFFFFFFFFF #ime6 FFFFFFFFFFFFFFF
E(me o$ Super"isor6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
Sign(ture (nd #itle o$ Person Prep(ring Report6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te6 FFFFFFFFF
Super"isor 'omments6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
Super"isor Sign(ture6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te6 FFFFFFFF
Correcti&e ction Ta!en/Follo.-(p' 9#hings th(t h("e !een or 5ill !e t(ken to pre"ent recurrence;
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
>irector 'omments6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
>irector Sign(ture6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te6 FFFFFFFF
Eursing Administr(tor Sign(ture6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te6 FFFFFFFF
Administr(tor Sign(ture6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te6 FFFFFFFF
Sign(ture o$ Person m(king 'ompl(int6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te6 FFFFFFFF
Worker 'ompens(tion $irst Report Sent6 FFFFF es FFFFF no >(te6 FFFFFFF OSHA &00 *og G 6 FFFFFF
FFFFF % underst(nd the potenti(l risks rel(ted to the e-posure to the incident th(t occurred (nd (gree to
recei"e (n e-(min(tion (nd/or tre(tment $or the e-posure3 (s recommended ! m phsici(n. #his
includes serologic(l testing $or Hep(titis 8 (nd the H%2 "irus (s indic(ted.
FFFFF % underst(nd the potenti(l risks rel(ted to the e-posure incidents th(t occurred (nd >O EO# (gree
to h("e (n e-(min(tion or tre(tment $or the e-posure.
Emploee Sign(ture6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te6 FFFFFFFFFFF
Super"isor Sign(ture6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te6 FFFFFFFFFFF
% underst(nd the in$orm(tion (!o"e 5ill !e used ! m emploer to help determine li(!ilit $or in7ur. %
(ckno5ledge th(t the (!o"e st(tements (re true (nd (ccur(te represent(tion o$ the requested
in$orm(tion.
Emploee Sign(ture6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te6 FFFFFFFFF
Ho! #itle6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
#esting $or H826 8(seline (nd + monthsI
#esting $or H%26 8(seline3 + 5eeks3 & months3 + months3 (nd 1 e(rII
'urrent re$erences m( !e $ound on the '>' 5e!site6 555.cdc.go" A9=or!idit (nd =ort(lit Weekl
Report J==WRK3 Hune 2/3 2001/2ol.<0/Eo.RR,11 or l(test "ersionB@ =or!idit (nd =ort(lit Weekl
Report J==WRK3 Septem!er &03 200</2ol.<)/Eo. RR,/3 upd(te;
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*/ORTOR+ INCIDENT REPORT
Document the incident: #od(4s >(te6 FFFFFFFFFFFFFFFFFFFF
He(lth >ep(rtment E(me6 FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
Who 5(s in"ol"edL
%n,house
E-tern(l3 person in"ol"ed 9i$ (n; FFFFFFFFFFFFFFF Org(ni:(tion FFFFFFFFFFFFFF
When did it h(ppenL
>(te o$ incident FFFF/FFFF/FFFF #ime6 FFFFFFFFFFFFFFFFFFFFFFFFF
Ho5 did the incident come to our (ttentionL
W(s in"ol"ed
Reported to me
Other FFFFFFFFFFFFFFFFFFFFFFFFF
#pe o$ incident6
'leric(l/>(t( Entr #esting Process Other FFFFFFFFFFFF
'ommunic(tions Result Reporting
Pro$icienc #esting S($et
>escri!e the incident6 9include multiple "ersions 5hen (pplic(!le;
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
%ncident Reported 86
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
Sign(ture >(te Sign(ture >(te
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Initial Re&ie. Process' 9#o !e completed ! the *oc(l Super"isor (nd/or 'o,director (nd
other essenti(l personnel3 (s needed. 8rie$l descri!e the outcome o$ the incident
in"estig(tion3 include (n necess(r pl(n o$ correcti"e (ction or (n polic ch(nge to !e
implemented.;
Re"ie5er4s
summ(rFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
Sign(ture FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te FFFFFFFFFFFFFFF
*aborator% Director0s Re&ie.' 9Follo5ing the initi(l loc(l re"ie5 (nd e"(lu(tion3 ple(se
cop to the St(te *(! >irector $or re"ie5.;
>irector4s summ(r FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
Sign(ture FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te FFFFFFFFFFFFFFF
Follo.-up Re&ie.' 9#o !e per$ormed & months $rom the initi(l d(te $iled. A$ter the remedi(l
(ction h(s !een monitored (nd e"(lu(ted $or e$$ecti"eness. %$ the incident h(s not !een
s(tis$(ctoril resol"ed3 the Super"isor (nd/or 'o,director should repe(t the %niti(l Re"ie5
Section3 per$orming monthl re"ie5s3 (nd (ddition(l remedi(l (ction until s(tis$(ctor
resolution is (tt(ined.;
H(s the %ncident recurred since the %niti(l Re"ie5L
DES
EO
Follo5,up Re"ie5er4s summ(r FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
Sign(ture FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te FFFFFFFFFFFFFFF
Filing the F%E%SHE> Report6
Sign(ture FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF >(te FFFFFFFFFFFFFFF

POST-E1POS(RE INCIDENT
SO(RCE INDI2ID(* CONSENT FOR)
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
P(tient E(me 9P*EASE PR%E#; Soci(l Securit Eum!er
Infor$ed Consent to /lood Testin"
% h("e !een in$ormed th(t (n indi"idu(l h(s !een e-posed to m !lood or !od $luids. As (
result o$ the e-posure3 % h("e !een (sked to permit m !lood to !e tested $or H%2 9kno5n to
c(use A%>S;3 H82 (nd H'2.
9'heck One;
% here! gi"e m consent to such testing.
% consent to h("e m !lood tested $or H823 !ut % decline to h("e m !lood tested $or H%2
(t this time. % underst(nd th(t ! choosing this option3 ( s(mple o$ m !lood 5ill !e kept
$or /0 d(s3 during 5hich period % m( ch(nge m mind (nd h("e m !lood tested $or
H%2 (t th(t time.
= consent is !(sed on the underst(nding th(t6
1. = test results 5ill rem(in con$identi(l (nd pro"ided onl to those 5ho h("e (
need to kno5 in (ccord(nce 5ith current $eder(l3 st(te3 (nd loc(l st(tutes.
2. % h("e !een pro"ided 5ith in$orm(tion concerning H%2 (nd H823 (nd underst(nd
the contents thereo$.
&. % h("e !een gi"en the opportunit to (sk questions concerning H%2 (nd H82
testing.
). % 5ill recei"e ( cop o$ (ll test results.
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Signed >(te
E$plo%er0s Representati&e
% certi$ th(t the (!o"e,n(med indi"idu(l recei"ed ( cop o$ the H%2/H82 in$orm(tion sheets (nd
h(s h(d the contents thereo$ $ull e-pl(ined.
FFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
>(te Emploer4s Represent(ti"e 9P*EASE PR%E#;
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
#itle
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
Sign(ture
#his document 5ill !e ret(ined in the e-posed emploee4s medic(l $ile.
POST-E1POS(RE INCIDENT
E1POSED E)P*O+EE CONSENT FOR)
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Emploee E(me 9P*EASE PR%E#; Soci(l Securit Eum!er
E$plo%ee Consent to /lood Testin"
As ( result o$ m e-posure to !lood or other potenti(ll in$ectious m(teri(l3 it is recommended
th(t % h("e m !lood tested $or H%2 9kno5n to c(use A%>S;3 H82 (nd H'2.
9'heck One;
% here! gi"e m consent to such testing.
% consent to h("e m !lood tested $or H823 !ut % decline to h("e m !lood tested $or H%2
(t this time. % underst(nd th(t ! choosing this option3 ( s(mple o$ m !lood 5ill !e kept
$or /0 d(s3 during 5hich period % m( ch(nge m mind (nd h("e m !lood tested $or
H%2 (t th(t time.
= consent is !(sed on the underst(nding th(t6
1. = test results 5ill rem(in con$identi(l (nd pro"ided onl to those 5ho h("e (
need to kno5 in (ccord(nce 5ith current $eder(l3 st(te3 (nd loc(l st(tutes.
2. % 5ill !e pro"ided 5ith counseling 5hether the tests (re neg(ti"e or positi"e.
&. % h("e !een pro"ided 5ith in$orm(tion concerning H%2 (nd H823 (nd underst(nd
the contents thereo$.
). % h("e !een gi"en the opportunit to (sk questions concerning H%2 (nd H82
testing.
<. % h("e recei"ed risk !eh("ior guidelines concerning H%2.
+. % 5ill recei"e ( cop o$ (ll test results.
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Signed >(te
E$plo%er0s Representati&e
% certi$ th(t the (!o"e,n(med indi"idu(l recei"ed ( cop o$ the H%2/H82 in$orm(tion sheets (nd
h(s h(d the contents thereo$ $ull e-pl(ined.
FFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
>(te Emploer4s Represent(ti"e 9P*EASE PR%E#;
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
#itle
FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
Sign(ture
#his document 5ill !e ret(ined in the e-posed emploee4s medic(l $ile.