EXPOSED MEMBER'S NAME: ___________________________________________RANK:__________________
 

SOCIAL SECURITY #__________________________________________ HOME PHONE:___________________
 

INCIDENT #:________________ SHIFT:______________ STATION:__________________
 

NAME OF PATIENT:_____________________________________________________________SEX:__________
 

ADDRESS:_____________________________________________________________________AGE:_________
 

SUSPECTED OR CONFIRMED DISEASE:_________________________________________________________
 

TRANSPORTED TO:____________________________________________________________________________
 

TRANSPORTED BY:____________________________________________________________________________
 

DATE OF EXPOSURE:_______________________________ TIME OF EXPOSURE:_______________________
 

TYPE OF INCIDENT (AUTO ACCIDENT, TRAUMA):__________________________________________________
 

WHAT WERE YOU EXPOSED TO:

_____ BLOOD _____TEARS _____FECES _____URINE _____SALIVA _____VOMITUS _____SPUTUM _____SWEAT _____OTHER:_____________________________
 

WHAT PART(S) OF YOUR 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:__________

CONTACT INFECTION CONTROL OFFICER: DATE__________ TIME:_________
 

SUPERVISOR'S SIGNATURE:______________________________________________DATE:_______________
 

MEMBER'S SIGNATURE:_________________________________________________ DATE:_______________