Attachment 4 Potential exposure to BBP.pdf

Attachment 4

POTENTIAL EXPOSURE TO BLOODBORNE PATHOGENS

Instruction to the Employee

You have been potentially exposed to blood of other body fluid while at work. OSHA requires that you be medically evaluated within 24 hours of this incident.

You are being sent to ___________________________ for this evaluation. When you arrive, present this letter to the Emergency Room personnel.

Information for the Physician

1. The employee has been potentially exposed to blood or other body fluids while working at the Defense Supply Center Columbus Facilities. An exposure incident form, filled out by the first responders, should be attached to this letter.

2. Please medically evaluate this employee per the requirements of your Bloodborne Pathogens protocol to determine if the exposure was significant.

3. Once you have evaluated this employee:

a. If a potential exposure has occurred, please refer the employee to a physician of the employee’s choice (e.g., you or the employee’s private medical doctor) for medical care.

b. If a potential exposure has not occurred, please send employee back to his/her work site and instruct employee to follow up appropriately.

Any questions concerning this evaluation, contact:

Contracting Officer’s Technical Representatives

Alison Duff or Amy Manbeck 614-692-4220 614-692-1663

Attachment 4

Exposure Incident Form

Employee’s Name: ______________________________________________

Exposure Date: _______________________ Exposure Time: _____________________________ Bldg, Area: ____________________

Please circle all that apply:

Good Samaritan Trained in First Aid/CPR First Responder

Type of Exposure: Type of Fluid:

Abrasion Blood Urine

Bite Feces Mucus

Laceration Saliva Other

Needle Stick Semen

Puncture Vaginal Fluid

Splash Vomitus

Body Parts Exposed: Amount of Fluid:

Head Less Than One Drop

Face One Drop to One Teaspoon

Torso Over One Teaspoon

Arms Unknown

Hands

Legs Exposed Skin:

Feet No Break in Skin

Other Skin Broken (Explain If Necessary)

Pre-Exposure Protection: Post-Exposure Precautions:

Gloves Wash Exposed Area with Water

Eye Protection Wash Exposed Area with Soap and Water

Coveralls Wash Exposed Area with Antimicrobial Wipe

Respirator Wash Exposed Area with Other

Infectious Risk:

Source Individual: First Aid Provider/Bystander:

HIV HIV

Hepatitis Hepatitis

STD (Gonorrhea, Syphillis) STD

Tuberculosis Tuberculosis

Other Other

Source Individual’s Name: __________________________________