Healthcare Decontamination Form

Healthcare Decontamination Form

This form documents the decontamination of a patient, staff member, or facility area following exposure to bodily fluids, suspected infectious material, or other contamination hazards. Completion of this form constitutes a record of the exposure event, the decontamination measures performed, waste handling, and any follow-up recommendations. The undersigned certify that the information recorded is accurate and that decontamination was performed in accordance with applicable infection control procedures.

Facility and Incident Information

Incident Date:   Time:   Location/Unit:

Patient / Affected Individual Information

Full Name:

Date of Birth:   Gender:

Insurance & Medical History

Policy Number:   Group Number:

Contamination / Exposure Details

Type of Contamination (check all that apply):

Blood   Vomitus   Urine   Saliva   Other:

Source Known: Yes    No    If yes, identify source:

Decontamination Procedure Performed

Method(s) used (check all that apply):

Soap and water   Disinfectant   Wipes   Steam   Other

If disinfectant used, product name and concentration:

Personal Protective Equipment (PPE) used (check all that apply):

Gloves   Gown   Eye protection   Mask/Respirator   Other

Decontamination Start Time:   Completion Time:

Waste Handling and Environmental Controls

Disposal Method (check all that apply):

Biohazard bag   Sharps container   Routine waste (non-regulated)   Other

Follow-up, Reporting, and Recommendations

Incident reported to infection control: Yes    No

Employee exposure report completed: Yes    No

Referred to:   Appointment Date:

Patient Consent, Acknowledgment, and Certification

By signing below, I authorize the identified decontamination procedures described in this record. I acknowledge that the decontamination team has explained the nature of the procedures performed, the reasons for the procedures, and the foreseeable benefits and risks. I understand that decontamination is being performed to reduce infection risk and to protect the health and safety of the patient and staff. I acknowledge my right to ask questions and to withdraw consent where feasible, and I acknowledge that certain reporting requirements for occupational exposures and reportable conditions may apply.

I acknowledge that this decontamination record may be included in my medical record and released to public health authorities or other authorized entities as required by law for exposure reporting or infection control investigations.

I acknowledge and consent to the decontamination procedures and disclosures described above.

Certification: I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge, that the decontamination procedures were performed as documented, and that any subsequent changes will be reported and appended to this record.

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