APPENDIX F - Notice of Specific Biohazard Exposure Incident


 

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Notice of Specific Biohazard

Exposure Incident


 

Date _____________________ Employee Name ____________________________________

 Route of Exposure:

__ Eye

__ Needle Stick

__ Non-intact skin

__ Other (Describe) _____________________________  

Describe the Incident __________________________________________________________

___________________________________________________________________________

___________________________________________________________________________  

Action taken following the incident ________________________________________________

___________________________________________________________________________

___________________________________________________________________________  

Was medical advice or treatment sought?  __yes  __  no

If so, provide name and phone number of medical provider:

___________________________________________                                                    ___________________________________________

 

     
Employee Signature   Date
     
     
     
Supervisor Signature   Date

 

 

Consent to draw and to test blood for HBV/HIV 

     
Employee Signature   Date

 

 PLEASE NOTE:  This form must be filled out and provided to the Environmental Health and Human Resources as soon as possible following the incident.

 

 

Gary Lee
Director, Environmental Health

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