COMMUNICABLE DISEASE RISK EXPOSURE REPORT
The filing of this report and all information entered on it are to be held in strictest confidence in conformance with 63 O.S. Supp. 1988, Section 1‑502.1, et seq.
EXPOSED WORKER SECTION (Please Print)
1. Employee Name:_______________________________________________________ 2. Birthdate:___________________
(Last) (First) (Middle Initial) Mo/Day/Yr
3. Profession/Job Title:_________________________ 4. Employer/Company Name:________________________________
5. Work Site/Telephone:_________________________________________________ Tel. Ext. #:_______________________
(Site) (Street Address)
6. Home Address/Telephone:_____________________________________________________ (_____)_________________
(Street) (City) (Zip) AC Telephone #
7. Supervisor's Name/Telephone:__________________________________________ Tel. Ext. #:_______________________
(Last) (First)
8. Date of Exposure: (Mo/Day/Yr) _______/_______/_______ 9. Time of Exposure:______________________ AM or PM (Circle One)
10. Detailed Description of Potential Exposure:________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
11. Exposed Worker ________ has ________ has not completed the full series of Hepatitis B vaccine.
12. Source Person's Name:________________________________________________________________________________
(Last) (First) (Middle Initial)
13. Disposition of Source Person (include address):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
TO BE COMPLETED BY EMPLOYER'S DESIGNEE
The employer agrees to be responsible for all reasonable charges incurred in the disposition of this risk exposure incident.
Employer Designee Reviewing Form:
14. Name ________________________________________ 15. _________________________________ 16. _______/_______/_______
(Please Print) Signature (Mo/Day/Yr)
TO BE COMPLETED BY THE EMPLOYER'S PHYSICIAN
_____ In my professional judgment, this was a parenteral, permucosal, or significantly cutaneous exposure to blood or other body fluids which has the potential for transmission of a communicable disease such as Hepatitis B, HIV, or meningococcus. Post exposure evaluation procedures and counseling should be provided. The employee has been told about any medical conditions resulting from exposure that requires further treatment.
_____ This incident does not constitute an exposure under the OSHA standard. NOTE: If this exposure does not warrant medical follow-up, please return the form to the Employer's Designee and indicate to that individual why it does not need follow-up.
_____ The employee has received or is beginning the Hepatitis B vaccination series.
17. ____________________________________ 18. ________________________________________ 19. _______/_______/_______
Physician's Name (Please Print) (Physician's Signature) (Mo/Day/Yr)
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