Appendix D  

San Juan College

Environmental Health Office

BLOODBORNE PATHOGENS

EMPLOYEE

HEPATITIS B OCCUPATIONAL RISK ASSESSMENT FORM

 Supervisor:

 Occupational risk to bloodborne pathogens is defined as reasonably anticipated contact with blood and/or body fluids that may result from the performance of an employee's duties (at least once a month).  Please complete this form for each employee for which this definition would apply.  Then return this form to the Environmental Health Office located in the East Classroom Complex.  I will then contact you to discuss, and to schedule a time for training regarding Bloodborne Pathogens and information about the Hepatitis B vaccine, if appropriate. The training and consultation is provided at no cost.  Please feel free to call  with any questions. 

Thank you,

San Juan College Environmental Health Office

(505) 566-3063

DEPT.___________________________       SUPERVISOR_________________________________  

DATE_______________________   

EMPLOYEE NAME_________________________________

PHONE EXT.______________  

JOB TITLE________________________________       

EMPLOYEE’S SHIFT__________________  

Reason(s)/ job responsibilities that may require employee to receive Hepatitis B vaccine: 

After the training has been completed, we will schedule employee vaccination.

NOTE: The Hepatitis B vaccine is voluntary and is to be provided at no cost to the employee.

Gary Lee

Director, Environmental Health

San Juan College
4601 College Blvd.
Farmington, NM  87401
(505) 566-3063