Form L: Refusal of Post-Exposure Follow-up

EMPLOYEE INFORMED REFUSAL OF POST-EXPOSURE MEDICAL EVALUATION

I, , am employed by ( school district ) . My employer has provided me training in bloodborne pathogens policies and the risk of disease transmission in the school. On (date) , 20 , I was involved in an exposure incident when I (describe incident)





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My employer has offered to provide follow-up medical evaluation for me in order to assure that I have full knowledge of whether I have been exposed to or contacted an infectious disease from this incident.

However, I, of my own free will and volition, and despite my employer's offer, have elected not to have a medical evaluation. I have personal reasons for making this decision.

Signature

Witness

Name

Address

City, State, Zip

Date

Note: Maintain this record for the duration of employment plus 30 years.