CONFIDENTIAL FOR HOSPITAL USE ONLY

Any transporter who has one of the exposures listed in (#2) below must complete this form immediately. The completed form should be placed in the designated receptacle provided by the hospital where the patient is delivered. ITEMS 1 – 5 are to be completed by the transporter. Questions in the box are to be completed by the hospital.

PLEASE PRINT LEGIBLY

ITEMS 1 – 5 TO BE COMPLETED BY THE TRANSPORTER:

1. The exposure described in (#2) below occurred in the care of the following patient/person:

___________________________________________ / on ____/____/____ at _________ AM/PM

(Patient Name) (Date) (Time)

taken to: ________________________________________________________________________

(Hospital / Facility)

CONFIDENTIAL: HOSPITAL, AFTER COMPLETION SEND TO HEALTH AUTHORITY

HOSPITALS: Cut on dotted line above and send lower portion only to your health authority. You may wish to keep a copy for your records.

2. Describe the details of contact with blood or body fluids.

TYPE OF EXPOSURE

ADDITIONAL DESCRIPTION

(Check those that apply)

___ Mouth-to mouth resuscitation _________________________________________________

___ Intubation _________________________________________________

___ Throat exam _________________________________________________

___ BLOOD AND/OR

___ BODY FLUID contact with:

___ Eyes _________________________________________________

___ Nose _________________________________________________

___ Mouth _________________________________________________

___ Puncture/cut with needle or sharp object __________________________________________

_________________________________________________

___ Open wound/lesion _________________________________________________

___ Non-intact skin _________________________________________________

SELF-FIRST AID MUST BE DONE AS SOON AS POSSIBLE FOLLOWING ONE OF THE ABOVE EXPOSURES. Rinse/flush thoroughly the body part exposed to Blood/Body Fluids. Follow with antimicrobial scrubbing of the exposed area, if not contraindicated, (i.e. eyes, etc.)

3. TRANSPORTER NAME: _________________________________________________________________

PHONE: (home) ______________________________________ (work) ____________________________

4. Name of Employer / Agency (EMS/Fire/Police): City of Ennis Fire Department

P.O. Box 220 Ennis, Texas 75120 972-875-1234

5. Transporter Signature: __________________________________ Date Form Completed: ___/___/___

Transporter; Now place completed form in the designated receptacle.

TO BE COMPLETED BY THE HOSPITAL

[] Disease* Identified ____________________________ ____/____/____

(name of disease) (date specimen collected)

[] No Disease* Identified during this hospitalization.

Reported to Health Authority by Telephone (For True Exposures Only)

Name of Agency:_____________________________________ Person Contacted:____________________________

Date Contacted: ____/____/____ By:______________________________________________________________

Name/Title of Person Completing this Section: ________________________________________________________ Signature:_____________________________________________ Date: ____/____/____