Health Care Professionals
Written Opinion For Post-Exposure Evaluation*

1. Employee Name:_____________________________________________
2. Date of Incident:_____________________________________________
3. Date of Office Visit:__________________________________________
4. Health Care Facility Address: __________________________________
5. Health Care Facility Telephone: ________________________________

As required under the Bloodborne Pathogen Standard:

______  The employee named above has been informed of the results of the post-exposure health evaluation.

______  The employee named above has been told about any health conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment.

______  Hepatitis B vaccination is ____ is not ____ indicated.

Signature of health care provider:_______________________ Date: ________      

Printed or typed name of health care provider:___________________________    

This form is to be returned to the employer, and a copy provided to the employee within 15 days.

Employer Name:______________________________

Title:_______________________________________

Address:_________________________________________________________

*This form was taken from: Model Exposure Control Plan for Home Care: A Guide for Hospice/Home Agencies on the Bloodborne Pathogens Standards. OSHA Office of Occupational Nursing, 1994.