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:_______________