Emergency Medical Service Provider Exposure Report Form {350}

Form 350 Emergency Medical Service Provider Exposure Report Form PLEASE PRINT OR TYPE Complete this form to document exposure to blood and/or other body fluids. Most unprotected exposures do not result in an infection, however, some people can be exposed to a disease and not have any symptoms of illness. It is important that you document any significant exposure incident. Significant Exposure ­ EMS Provider Information Exposed Provider, use your last initial, first initial, last 4 digits of Social Security number for ID # ex. (ab1234) ID # _________ Employee Name ________________________________________ DOB _____/_____/_____ Sex ________ (Last) (First) (M) M or F Home Phone _______________ Work Phone ________________ Employer/Agency _______________________ Contact Person at Employment / Agency ________________________ Contact Phone ______________________ Date _____________________ Incident # ______________________ Mechanism of Exposure (check all that apply) Body Fluid Exposure Other Body Fluid w/Blood Blood Saliva Birth Fluids Urine Pericardial Fluids Feces Pleural Fluid Pus Synovial Fluid Sputum Cerebrospinal Fluid Other Semen Vaginal Secretions How Were You Exposed? Splash in Eye Splash in Mouth or Nose Bite Puncture w/Hollow-bore Needle Puncture Cut w/Other Sharp Implement Open Wound Rash / Dermatitis Abrasion What protective equipment were you using at the time of exposure? (check all that apply) Bag-Valve-Mask One Way Resuscitation Mouthpiece Gloves N-95 Mask Eye Protection Surgical Mask (Less than N-95 rating Paper Gown Other Source of Significant Exposure ­ Source Patient Information Source Patient Name ____________________________________ Phone Number _______________ Source Patient Address __________________________________ (Street Address) DOB _____/_____/_____ __________________________________ (City, State, Zip) Sex: M _____F_____ I hereby give my permission to the facility named below to draw and test my blood for any or all of the following: HIV Antibody, HBV/Surface Antigen and, HCV Antibody. I understand that the results of this testing are private information and will be confidential. I refuse to have my blood drawn and tested. I understand that a court order may be pursued to require me to have blood testing done. Source Patient (or responsible) Signature ____________________________________________ Date ______/______/______ Receiving Facility/Testing Laboratory Receiving Facility _______________________________________________Date Specimen(s) were obtained _____/_____/_____ Testing Laboratory ______________________________________________Date Specimen(s) were submitted _____/____/_____ Did patient expire? Yes No Was the patient under the jurisdiction of the State Department of Corrections (Prisoner or Parolee)? Yes No Name of Person submitting report _________________________________________________________ Title _____________________________ Phone Number _________________ Date Report was submitted _____/_____/______ If onsite post exposure counseling is not available contact any of the following. http://www.ucsf.edu/hivcntr/Hotlines/PEPline.html 24/7 Or call (800) 537-1046. (801) 538-6096 or (800) FON-AIDS 8-5 M-F (hospital clinicians may receive 24/7 help with PEP counseling by calling 1-888-448-4911) The Laboratory must report the test results of the source patient testing to the EMS Agency/Employer Contact person listed above. * The EMS Agency/Employer must submit the Employer's First Report of Injury/Illness (Form 122) when this form is completed by an EMS Provider. 160 East 300 South * P.O. Box 146610 Salt Lake City, UT 84114-6610 * Telephone: 801-530-6800 Fax: 801-530-6804 * Toll Free: (800) 530-5090 * www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com Official Form 350 Revised 8/2012 State of Utah * Labor Commission * Division of Industrial Accidents