Accidental Blood Exposure

  
An accidental exposure means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or OPIM.  In the event of an accidental exposure to an employee, the procedure is as follows:

1.   Immediate first aid- Employee will wash the exposed site thoroughly with soap or disinfectant and water. Flush eyes and/or mucous membranes with water immediately.

2.   Immediately report injury to supervisor and school nurse. If immediate supervisor is not available, report to another school administrator.

3.  The school nurse or supervisor will arrange for a medical post-exposure evaluation and follow-up.

4.  Required forms to be completed within 24 hours are:

a. Employee Injury Report, using back of form as needed to describe in full how the exposure to blood or body fluid occurred.
b. Supervisor’s Injury Report

5.  The school nurse will meet with the employee.

a. The employee will be given bloodborne pathogen information.
b. Blood collection and testing will be discussed.
c. The employee will be referred to the School Doctor’s office for a medical post-exposure evaluation. The form, Medical Care Provider Report will be accompany.
d. The employee will be informed of laws concerning disclosure of identity of source individual.

6.  If the source individual is known, the school nurse will assist in making arrangements to have the source individual tested for HIV, HBV, and HCV infectivity. 

7.  The school nurse will meet with the employee after all data has been collected to complete a Follow-up Outcome Report and discussed any additional concerns.

8.  Flow of completed forms:

a. Original copies to Superintendent’s office.
b. Retain copy of each form for employee’s personnel file.

 

  
Date_________________
 
Employee’s Name _________________________________________   DOB_________________
              
 
The above named individual was seen by me today following an accidental exposure to blood.
 
 
Blood was collected for HBV, HCV, and HIV serological testing:   YES______        NO_____
 
Serological testing was done at this time: ____________
 
Blood was collected, but the employee declined baseline testing at this time:   YES_____  NO_____  
 
Blood will be held for 90 days   YES_____  NO_____
 
 
My recommendation is as follows:
 
     Hepatitis vaccine required:      YES______  NO_____
      
     Initial dose administered:        YES______  NO_____ Date (if yes)  __________________                          
                                                     
 
 
Signature__________________________________________________Date__________________
 
 
Please print name and address of Health Care Provider completing this report:
 
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
 

 
Employee Name: _________________________________________________________________
Title ____________________________________ Social security # _________________________
Date of Exposure Incident __________________________________________________________
Employee’s Report of Injury Filed  _______ Yes ______ No
A. Source Name (if individual known) _________________________________________

Consent for Blood Testing Obtained ______ Yes _____ No Date _________
Source Blood Tested for HIV, HBV and HCV and Report Received Date ________
Comments:

 B. Employee
 
  Blood Collected  _________ HBV ________ HIV
  And  Tested  _________ HCV ________ Declined Blood Testing
  Hepatitis B  ______ No prior Hepatitis B vaccination or incomplete series
     ______ HBIG (Hepatitis B Immune Globulin) received
     ______ HBV vaccinated – received three doses previously
     ______ HBV series started
  HIV & Hepatitis C ______ Risk Counseling Offered
  Tetanus  ______ Current within 10 years
     ______ Suggest booster through employee’s physician
  Counseled  ______ Informed of laws and regulations concerning
       Disclosure of source individual identity
     ______ Received current/appropriate health ed materials
  Comments:
 
Post exposure Medical Evaluation Completed by: _____________________________________
_____________________________________________________________________________
Written opinion form health care professional obtained if appropriate _____________________
Report Filed By: _______________________________________   Date: _________________ 

Employee Incident form

 
• REMINDER:  If your employer has a primary care physician, initial treatment must be through their office.  In case of an emergency, proceed to the nearest medical facility.
 
This report is requested even though you may have reported this injury to your Supervisor.
Name  ____________________________________________________________________________________
Address _____________________________________________________________  Phone________________
SS# __________________  Gender ______ Date of Birth __________Date of Hire________#Dependents_____  
Employer/School ____________________________________________________________________________
Supervisor _________________________________________________________________________________
Occupation when injured  _______________________________  Secondary Employment _________________
Were you doing your regular work? _______________________  If not, what work? ______________________
Date of injury ________________________________________  Hour of day  __________ AM ____ PM ____
Exact place where injury occurred ______________________________________________________________
Describe fully how injury occurred _____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe your injury in detail (mention body parts affected) (specify (L) or (R) side)______________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you have any pre-existing or contributory Injuries/Conditions? ____________________________________
__________________________________________________________________________________________
Names of any witnesses ______________________________________________________________________
__________________________________________________________________________________________
Name of doctor treating you _____________________________  First Date seen: ________________________
Address ___________________________________________________________________________________
Name and addresses of other medical providers seen _______________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Did you lose time from work? ___________  If so, when did disability start?_____________________________
Have you returned to work?  ____________ When? ________________________________________________  
Light Duty _______ Regular Duty _______ Number of Hours __________ Rate of Pay  ___________________
To whom was injury reported? __________________________When (date)?____________  AM ____ PM____
 
______________________________                  _______________________________________________
                      Date                                                                                  Signature
 
J:bjb:data:ee report.doc(08/06)

Supervisor's Incident Report Form

 
This report should be completed within 24 hours of the incident while the facts are still fresh in the minds of witnesses and should be filed with the department responsible for the processing of Workers’ Compensation claims.

Name of injured employee ____________________________________________________________________
Occupation when injured  _______________________________  School _______________________________
Was employee performing regular occupation? ______________   If not, what occupation? ________________
Was employee experienced/trained in this occupation?_________  Secondary Employment?________________
Date of injury ________________________________________  Hour of day  __________ AM ____ PM ____
Describe the events which resulted in the injury or disease ___________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Primary Cause of Injury ____________________________________________________________________
__________________________________________________________________________________________
Action taken to prevent
recurrence______________________________________________________________
Describe the injury /disease and indicate body parts affected (specify (L) or (R) side) _____________________
__________________________________________________________________________________________
Do you have any questions or concerns pertaining to this injury?   Yes _____________  No ________________
If  “yes,” please explain ______________________________________________________________________
__________________________________________________________________________________________
Are you aware of any pre-existing or contributory injuries/conditions?__________________________________
__________________________________________________________________________________________
Name(s) of any witnesses _____________________________________________________________________
Was medical treatment provided? _______________________________________________________________
__________________________________________________________________________________________
Were you notified by the injured employee of this injury? __________  If so, when? ______________________
Did employee lose any time from work? _____________  If so, when did disability start? __________________
Has employee returned to work? ___________________ When? ______________________________________  
Light Duty _______ Regular Duty _______ Number of Hours __________  Rate of Pay ___________________
Any Light Duty work available? ________________________________________________________________
 
________________________________  ________________________________________________
                      Date                                                                                          Signature
 
________________________________ ________________________________________________
                Phone number                             (Position and Department)
 
J:bjb:data:er report.doc(08/06)
Doctor:
Hospital:
$

Medical Emergency Form

 
 
 
Site _______________________________  Date _________________  Time ________________
 
 
Name of person with medical emergency_____________________________________________
              
Nature of emergency ____________________________________________________________
 
_______________________________________________________________________________
 
_______________________________________________________________________________
 
      
First aid administered at the scene __________________________________________________  
 
_______________________________________________________________________________
 
_______________________________________________________________________________
 
Administered by _________________________________________________________________
 
911 called by ___________________________________________  Time ___________________
 
Parent/Guardian called by _________________________________ Time ___________________
 
Taken by ambulance to  ___________________________________ Time ___________________
    (Name of Hospital)
 
Person completing this form _______________________________________________________
       Signature
 
 
 

School Incident Report Form

 
Please complete one form for each “incident of prohibited behavior” which occurs on school property
during school hours or during school sponsored activities.
 
Date of Incident_________ Person completing form______________________ School__________________
 
OFFENDER(S)______________________________ Age____  Grade____  M or F____ Special Ed.____
 
                 ______________________________ Age____  Grade____  M or F____ Special Ed.____
 
 
VICTIM(S)____________________________________  Age_______  Grade_______   M or F______
 
  ____________________________________ Age_______  Grade_______   M or F______
 
 
VIOLENCE INCIDENT:  Fighting_____ Pushing_____ Stealing_____  Swearing_____  
 
Threat/Intimidation____ Hate Crime____ Harassment____ Sexual Offenses____ Racial/Sexual Bias_____
 
Describe what happened____________________________________________________________________
 
 
VANDALISM INCIDENT:   Describe what happened_______________________________________
__________________________________________________________________________________________
 
 
SUBSTANCE ABUSE:  Describe (Alcohol, Marijuana, Tobacco, etc.)___________________________
__________________________________________________________________________________________
 
 
WEAPONS:  Describe incident_____________________________________________________________
 
__________________________________________________________________________________________
 
ACTION TAKEN:
 
1. Detention or loss or privilege____
 
2. In school suspension____
 
3. Out of school suspension____
 
4. Alternative placement_____
 
5. Expulsion from school_____
 
6. Law enforcement referral_____

Student Accident Report Form

 
1. Name: ____________________________________     Sex:       1.   Male    2.     Female     Grade ______    Age ______
 
2. School Name: ________________________________ Date Occurred: ____/____/____ Date Reported: ____/____/____  
 
3. Time:  _____________ A.M./P.M.  01 Before School Hours 02 During School Hours
       03 After School Hours 04 School not in Session
 
4. Place of Accident:

** Other (explain) __________________________________________________________
 
5. Source of Injury:

    ** Other (explain) __________________________________________________________
 
6. Body Part Injured:

    ++ No Noticeable Injury        
    ** Other (explain) ___________________________________________________________
 
7. Nature of Injury:

** Other (explain) ___________________________________________________________
 
8. Narrative Description of Accident: ________________________________________________________________________
 ______________________________________________________________________________________________________
 ______________________________________________________________________________________________________
 
9. Names of Witnesses: ________________________________________________________________________________
 
10. Action Taken: 

 ** Other (explain) __________________________________________________________
 
Signature ______________________________________________________________________  Date _________________
 
Nurse Assessment: ___________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________Nurse’s Signature__________________________________