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Addendum two. Date of Report: <br /> Emergency Medical Services (EMS) Personnel <br /> COMMUNICABLE DISEASE EXPOSURE REPORT FORM <br /> (EMS) Employee If you wish to be evaluated, complete entire form See back sheet for Directions) to <br /> As an employee y in e orderrto emergency low dica to apidly treat are <br /> ou aexposure to blood and to information <br /> ack theusource this <br /> pat patient. In <br /> a health care facility <br /> addition, we are requesting that you provide a blood sample sot at you can be tested for hepatitis B and for the presence the virus of antibodies for the human <br /> any counseling and treatment may need as a esult blood xposu e. By signingg consent you a e authorizing <br /> permission pr ivate our (nonpublic) the presence of antibodies to hepatitis esgnated t results blood <br /> gency which <br /> employs you, and, if your test results are positive, to the Minnesota Department of Health. <br /> You re not youryemplormentBdHowe er u s you s report youreoccupational xposur failure <br /> to body fluidsuand will <br /> provide <br /> information and a blood sample, the health care facility will not be able to determine if this exposure may have transmited <br /> HIV or hepatitus B. <br /> By signing here, you are authorizing permission to test your blood for the presence of HIV antibodies. <br /> Date Name (exposed EMS worker) <br /> By signing below, you are authorizing permission to test your blood for hepatitus B. <br /> Date Name (exposed EMS worker) <br /> If you request it, your employer must pay for the cost of counseling, testing, and costs associated with the testing of both <br /> you and the patient to whom you were exposed (source patient). <br /> 1. Date of Incident 2. Employee's Agency <br /> Time of Incident Name <br /> Vehicle Run Agency Phone <br /> Location Agency Address <br /> 3. Name of EMS Medical Director for Employee Medical Director's Address <br /> Drs. L.A. Long R.J. Frascone Office of EMS, SPRMC <br /> Medical Director's Phone 612) 221 -3991 St. Paul MN 55101 <br /> (Town) (State) (Zip) <br /> 4. First Evaluation Site: 5. Follow -up Appointment Site: <br /> Facility Name: Facility Name: <br /> Address: <br /> Address: <br /> (Town) (State) (Zip) (Town) (State) (Zip) <br /> Telephone: <br /> Telephone: <br /> 6. Circumstances of Contamination (Check Appropriate Boxes) <br /> a. wearing gloves? No Yes h. mouth -to -mouth resuscitation using an airway? <br /> b. drawing blood No Yes <br /> c. IV insertion If Yes, What type? <br /> d. needlestick injury i. a human bite that caused a break in the skin <br /> e. recapping a needle j. splash from actively bleeding patient <br /> f. puncture with a sharp object (not needle) k. labor and delivery <br /> g. laceration with a sharp object (not needle) I. other <br /> 7. Fluid Contamination 8. Exposed Part of Employee's Body <br /> (Check Appropriate Box) (Check Appropriate Box) <br /> a. blood a. skin <br /> b. saliva b. mouth nose <br /> c. emesis c. eyes <br /> d. amniotic fluid d. a wound that was less than 24 hours old <br /> e. other? e. a wound that was more than 24 hours old <br /> f. other? <br /> 9. Patient Source Data M E <br /> a. Name: DOB Telephone <br /> b. Address <br /> c. Name of facility receiving patient: <br /> White ER receiving source Blue ER evaluating EMS exposed employee <br /> Pink Health Care provider doing follow -up Yellow EMS Chief Green EMS Exposed Employee 01/91 <br />