Post-Exposure Forms
- Replaces: Supersedes all previous information on the same topic
- Reviewed: Annually
- Section Revised: Split form Bloodborne Pathogens (BBP) Exposure Control Plan and Moved to Google Sites 1/1/2022; revised 1/1/2022,
- Contact: Employee Health Nurse
Medwatch Adverse Event Form (FDA Form 3500)
Use this form to document medication errors and employee exposure to BBPs.
MedwatchForm3500.pdfPhysician Letter / Physician Treatment Form
Use this form to obtain physician statements regarding an employee's exposure to BBPs at work.
Physician Letter.pdfPost Exposure Incident Consent Form - Exposed Employee Form
Use this form to obtain consent for testing from an employee who has been exposed to a BBP at work.
Post Exposure Employee.pdfPost Exposure Incident Consent Form - Source Individual Form
Use this form to obtain consent for testing from the source of an employee exposure to a BBP.
Post Exposure Source.pdfSt. Elizabeth Exposure Lab Requisition -Source Patient and Employee
Exposure-Lab Requisition-St. Elizabeth rev. 12-7-21.pdfThis form should accommodate the Employee to Business Health or the Emergency Department
This form should also accommodate the Source patient's blood to the St. Elizabeth Lab
24 hour courier to St. Elizabeth Lab-(859) 301-2170 to request pick-up and delivery
Sharps Injury Log Form
Use this form to record specific information about sharps injuries as they occur at your site.
Sharps Injury Log Form.docConsult the Employee Health Nurse with questions about these forms.