MSAD #4

  
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: _________________