Policy Manual sample

MDT Home Health Care Agency, Inc. EMPLOYEE EXPOSURE INCIDENT NAME OF EMPLOYEE: _____________________________________________________ JOB CATEGORY: __________________________________________________________ DATE OF EXPOSURE INCIDENT: ___________________________________________ ROUTE OF EXPOSURE: ____________________________________________________ ___________________________________________________________________________ CIRCUMSTANCES OF EXPOSURE INCIDENT: _______________________________ ___________________________________________________________________________ SOURCE INDIVIDUAL: 1. Name: ______________________________________________________________ 2. Address: ____________________________________________________________ ______________________________________________________________ 3. Telephone #: _________________________________________________________ 4. _____ Client 5. _____ Other (explain) __________________________________________________ 6. Known to be infected: HBV _____ Yes _____ No _____ Not Known 7. Blood Test obtained (Not needed if source individual is known to be infected.) _____ Yes _____ No/legally required consent cannot be obtained 8. If blood test obtained - results of the test: HBV _____________________________________________________________ HIV ______________________________________________________________ Home Health Agency Nursing Care & Procedures K-99