Adopted: 08/18/1988
Revised: 02/18/2008 523.4 Exhibit 6
School District of Prairie Farm
Information and Procedures in Dealing with Exposure
SCHOOL EXPOSURE INCIDENT INVESTIGATION FORM
Date of Incident: ____________________________ Time of Incident:________________
Location: _____________________________________________________________________
Persons Involved: _______________________________________________________________
Potentially Infectious Materials Involved:
Type: ______________________________ Source: _____________________________
Circumstances (what was occurring at the time of the incident): __________________________
______________________________________________________________________________
______________________________________________________________________________
How was the incident caused (accident; equipment malfunction, etc.) List any tool, machine, or equipment involved: _____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Personal protective equipment being used at the time of the incident: ______________________
______________________________________________________________________________
Actions taken (decontamination, clean-up, reporting, etc.): ______________________________
______________________________________________________________________________
______________________________________________________________________________
Recommendations for avoiding repetition of incident: __________________________________
______________________________________________________________________________
School District of Prairie Farm
Prairie Farm, WI
HEPATITIS B VACCINE DECLINATION
I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.
Employee Name (please print): ___________________________________________________
Employee Signature: ____________________________________________________________
Date: _______________________
HEPATITIS B VACCINATION RECORD
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given information on the hepatitis b vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge.
I, ________________________________ have completed the following inoculations using:
______ Recombivax-HB Vaccine or ______ Enerix-B Vaccine
--Inoculation 1 Date: ___________ Given at: _____________
--Inoculation 2 Date: ___________ Given at: _____________
--Inoculation 3 Date: ___________ Given at: _____________
Appendix G contains a copy of the WKC-8165 form: Medical Management of Individuals Exposed to Blood/Body Fluids. This form should be completed whenever a person has been significantly exposed (the statutory definition of a significant exposure is included with this form) to blood or body fluids. It is intended to be used for possible Worker's Compensation documentation. Specific instructions are detailed on the form. To obtain copies of WKC-8165 contact Document Sales at (608) 266-3358.
(The next pages would be this attachment)
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.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
__________ 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.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
__________ 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.
INFORMATION AND TRAINING OF EMPLOYEES
WITH
POTENTIAL EXPOSURE TO BLOOD BORNE PATHOGENS
Date(s) of Training: _____________________________________________________________
Trainer(s) Name and Qualifications: ________________________________________________
Names and Job Titles of All Employees Attending This Training: (Attached)
Agenda and/or Materials Presented to Training Participants Include:
- An accessible copy of the text of the DILHR Standard.
- A general explanation of the epidemiology and symptoms of blood borne diseases.
- An explanation of the modes of transmission of blood borne pathogens.
- An explanation of the exposure control plan and the means by which employees can obtain a copy of the written plan.
- An explanation of the appropriate methods of recognizing tasks/activities that may involve exposure to blood and other potentially infectious materials.
- An explanation of the use and limitations of methods that will prevent or reduce exposure: i.e., engineering controls, work practices, and personal protective equipment.
- Information on the types, proper use, location, removal, handling, decontamination, and disposal of personal protective equipment or other contaminated items.
- An explanation of the basis for selection of personal protective equipment.
- Information on the HBV vaccine, its efficacy, safety, method of administration, benefits of the vaccination and provision at no cost to the employees.
- Information on the appropriate actions to take and persons to contact in an emergency involving blood and other infectious materials.
- An explanation of the procedure to follow if an exposure incident occurs, the method of reporting, and the medical follow-up that is available.
- Information on the post-exposure evaluation and follow-up that is provided.
- An explanation of the signs, symbols, and color-coding of biohazards.
- A question and answer session between the trainer(s) and employee(s).
- Provisions of a list of contacts with the school districts and the health community that can be resources to the employees if they have questions after training.
Signature of Training Coordinator: _________________________________________________
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