Emergency Medical Service Provider Exposure Report Form. This is a Utah form and can be use in Workers Compensation.
Tags: Emergency Medical Service Provider Exposure Report Form, 350, Utah Workers Compensation,
Form 350 9/05 State of Utah – Labor Commission Division of Industrial Accidents 160 East 300 South, 3rd Floor - P O Box 146610 Salt Lake City, UT 84114-6610 (801) 530-6800 – (800) 530-5090 – Fax (801) 530-6804 Emergency Medical Service Provider Exposure Report Form Complete this form to document exposure to blood and/or other body fluids. Most unprotected exposures do not result in an infection, however, some people can be exposed to a disease and not have any symptoms of illness. It is important that you document any significant exposure incident. Significant Exposure – EMS Provider Information Exposed Provider, use your last initial, first initial, last 4 digits of Social Security number for ID # ex.(ab1234) ID # _________ Employee Name _____________________________________ DOB ___/___/___ Sex ________ (Last) (First) (M) M or F Home Phone _____________ Work Phone ______________ Employer/Agency ____________________ Contact Person at Employment / Agency ______________________ Contact Phone ___________________ Date _____________________ Incident # ____________________ Mechanism of Exposure (check all that apply) Body Fluid Exposure Other Body Fluid w/Blood Blood Saliva Birth Fluids Urine Pericardial Fluids Feces Pleural Fluid Pus Synovial Fluid Sputum Cerebrospinal Fluid Other Semen Vaginal Secretions How Were You Exposed? Splash in Eye Splash in Mouth or Nose Bite Puncture w/Hollow-bore Needle Puncture Cut w/Other Sharp Implement Open Wound Rash / Dermatitis Abrasion What protective equipment were you using at the time of exposure? (check all that apply) Bag-Valve-Mask One Way Resuscitation Mouthpiece Gloves N-95 Mask Eye Protection Surgical Mask (Less than N-95 rating Paper Gown Other Source of Significant Exposure – Source Patient Information Source Patient Name ____________________________________ Phone Number _______________ Source Patient Address __________________________________ (Street Address) DOB ___/___/___ __________________________________ (City, State, Zip) Sex M ___F___ I hereby give my permission to the facility named below to draw and test my blood for any or all of the following: HIV Antibody, HBV/Surface Antigen and, HCV Antibody. I understand that the results of this testing are private information and will be confidential. I refuse to have my blood drawn and tested. I understand that a court order may be pursued to require me to have blood testing done. Source Patient (or responsible) Signature ____________________________________________ Date ___/___/___ Receiving Facility/Testing Laboratory Receiving Facility __________________________________________________Date Specimen(s) were obtained ___/___/___ Testing Laboratory __________________________________________________Date Specimen(s) were submitted ___/___/___ Did patient expire? Yes No Was the patient under the jurisdiction of the State Department of Corrections (Prisoner or Parolee)? Yes No Name of Person submitting report _________________________________________________________ Title _____________________________ Phone Number _________________ Date Report was submitted ___/___/___ If onsite post exposure counseling is not available contact any of the following. http://www.ucsf.edu/hivcntr/Hotlines/PEPline.html 24/7 Or call (800) 537-1046. (801) 538-6096 or (800) FON-AIDS 8-5 M-F (hospital clinicians may receive 24/7 help with PEP counseling by calling 1-888-448-4911) The Laboratory must report the test results of the source patient testing to the EMS Agency/Employer Contact person listed above. * The EMS Agency/Employer must submit the Employer’s First Report of Injury/Illness (Form 122) when this form is completed by an EMS Provider. American LegalNet, Inc. www.USCourtForms.com