Exhibit 4 Infectious Substance Exposure Form.pdf
PDF 76 KB Posted
- Solicitation number
- SRC0000019823
- Issued by
- Ohio
About this file
This document is an Infectious Substance Exposure Form for the Ohio Air National Guard. The form captures information about members who have been exposed to infectious substances during the course of their duties, including details about the type of exposure, location of exposure on the body, how the exposure occurred, whether medical attention was sought, and any known allergies.
The related state and local contract opportunity is for the Ohio Air National Guard to contract with a professional medical organization to provide candidate firefighter and member firefighter annual medical evaluations in accordance with National Fire Protection Association (NFPA) 1582-2022 and the associated U.S. Air Force Technical Implementation Guide (TIG) 1582 2022 edition. The selected contractor will also serve as the designated fire department physician and provide post-infectious exposure care and testing per NFPA 1581 and 1582 standards.
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Text version
INFECTIOUS SUBSTANCE EXPOSURE FORM
Exposed Members’ Information
Name: Rank: Soc. Sec. #:
Unit: Office Symbol: Duty Phone:
Patient Information
Name of Patient: Sex:
Age: D.O.B. Address:
Suspected or Confirmed Disease:
Transported to: Transported by:
Type of Incident (auto accident, trauma):
Detailed Exposure Information
Date of Exposure: Time of Exposure: Incident Number: _________________
What was member/s exposed to?
Blood: Tears: Feces: Urine: Saliva:
Vomitus: Sputum: Sweat: Other:
What part(s) of the body became exposed? Be specific:
Did you have any open cuts, sores, or rashes that became exposed? Be specific:
How did the exposure occur? Be specific:
Did you seek medical attention? Yes No
Where? Date:
Do you have allergies to medicine? Yes No which medications?
Reported to Infection Control Officer: Yes No Date: Time:
Members Signature: Date:
Supervisors Signature: Date:
File details come from the government source that posted it. Updated .