Health Care Professionals
Written Opinion For Post-Exposure Evaluation*
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- Employee Name:_____________________________________________
- Date of Incident:_____________________________________________
- Date of Office Visit:__________________________________________
- Health Care Facility Address:__________________________________
- Health Care Facility Telephone:________________________________
As required under the Bloodborne Pathogen Standard:
______ The employee named above has been informed of the results of the post-exposure health evaluation.
______ The employee named above has been told about any health conditions resulting from exposure to blood or other potentially infectious
materials which require further evaluation or treatment.
______ Hepatitis B vaccination is ____ is not ____ indicated.
Signature of health care provider:_______________________ Date: ________
Printed or typed name of health care provider:___________________________
This form is to be returned to the employer, and a copy provided to the employee within 15 days.
Employer Name:______________________________
Title:_______________________________________
Address:_________________________________________________________
*For more information, see: Model Plans and Programs for the OSHA Bloodborne Pathogens and Hazard Communications Standards. OSHA Publication 3186 (2003), 521 KB PDF, 29 pages.
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