Form K: Exposure Incident Follow-up

EXPOSURE INCIDENT FOLLOW-UP

Exposure incident Date

Exposure Incident Form Completed Date

Exposure incident reported to supervisor Date

Medical evaluation Date

Information sent to health care professional Date

1. Copy of ( school district’s ) Exposure Control Plan
2. Employee's job description
3. Description of exposure incident (FORM J)
4. Results of source individual's blood tests (if known)
5. Employee immunization status (FORM N)

Source individual medical tests completed Date

Employee medical tests completed Date

Written report from health care professional Date

Hepatitis B vaccine given Date

Exposure incident reviewed Date