Adopted: 08/18/1988

Revised:  02/18/2008

                                                                                                                         523.4 Exhibit 3

School District of Prairie Farm

Information and Procedures in Dealing with Exposure

EMPLOYEE MEDICAL RECORD CHECKLIST

NAME: _______________________________________________________________________

BUILDING: ___________________________________________________________________

JOB CLASSIFICATION: ________________________________________________________

________  Copy of employee's hepatitis B vaccination record or declination form.  Attach any additional medical records relative to hepatitis B.

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________        Brief description of exposure incident: __________________________________

                        __________________________________________________________________

________        Log and attach this district's copy of information provided to the healthcare professional:

                        ________Accident report

                        ______Results of the source individuals blood testing, if available

                        ______ Log and attach this district's copy of the healthcare professional's written opinion.

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________        Brief description of exposure incident: __________________________________

                        __________________________________________________________________

________  Log and attach this district's copy of information provided to the healthcare  professional:

                        _____Accident report

                        _____Results of the source individual's blood testing, if available

                         ____ Log and attach this district's copy of the healthcare professional's written opinion.