Refusal Of Post Exposure Medical Evaluation printable pdf download

Refusal of Post-Exposure Medical Evaluation

for Bloodborne Pathogen Exposure

Weber State University – Environmental Health & Safety

Revised February 2001

Supervisor or Clinical Instructor: Print and complete this form only if the exposed individual refuses post-exposure

medical evaluation by a health care professional. Send this completed form to Environmental Health & Safety, mail code

3002.

Exposed Individual Information

Name:________________________________

WSU Department or Program:________________________________

Exposure Date:________________________________

Social Security Number:________________________________

Exposure Information

Facility and Department where the incident occurred:________________________________

Type of Protection equipment used (gloves, eye protection, etc.):________________________________

Describe how you were exposed:

______________________________________________________________________________________

Tell how this type of exposure can be prevented:

______________________________________________________________________________________

Statement of Understanding

I have been fully trained in WSU’s Exposure Control Plan, and I understand I may have contracted an infectious disease

such as HIV, HCV or HBV. I also understand the implications of contracting these diseases.

I have been offered follow-up medical testing free of charge by my employer to determine whether or not I have

contracted an infectious disease such as HIV, HCV, or HBV. I have also been offered follow-up medical care in the form

of counseling and medical evaluation of any acute febrile illness (new illness accompanied by fever) that occurs within

twelve weeks post-exposure.

Despite all the information I have received, for personal reasons, I freely decline this post-exposure evaluation and follow-

up care.

Exposed Individual's Signature:___________________________

Date: ____________________________

Witness Name:________________________________________

Signature:________________________________

Refusal Of Post Exposure Medical Evaluation