Healthcare HAZ Profile

HEALTHCARE HAZ PROFILE

Purpose: This Healthcare Hazard Profile documents personal, clinical and exposure-related information necessary for evaluation, post-exposure management, occupational health follow-up, and any legally required notifications. Completion of this profile authorizes the healthcare provider to collect and maintain the information herein for the purposes of diagnosis, treatment, exposure assessment, and occupational recordkeeping.

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance / Billing

Medical History & Immunizations

Chronic Conditions (select all that apply): Asthma Diabetes Chronic Kidney Disease None/Other

Hepatitis B: Documented    Incomplete/Unknown    Date(s):

TB Screening: Positive/Treatment Negative/No history    Date:

Occupational / Exposure Information

Date of Exposure / Incident:    Time:

Route(s) of Exposure: Inhalation Dermal Ingestion Percutaneous/Needlestick Other (specify below)

Personal Protective Equipment in Use at Time of Exposure: Gloves Gown Mask/Respirator Eye Protection None

Clinical Signs, Treatment, and Follow-up

Received Clinical Evaluation Today: Yes No

Risk Assessment & Administrative Actions

Preliminary Exposure Risk Level: Low Medium High

Authorization, Privacy, and Patient Acknowledgment

I authorize the healthcare provider to perform evaluation, testing and treatment that are clinically indicated for the exposure described. I understand that relevant findings may be documented in my occupational health record and may be released to my employer or designated public health authority as required by applicable law or workplace policy to ensure appropriate notification and post-exposure management.

I understand that my protected health information will be handled in accordance with privacy protections and that my consent for routine workplace notification does not waive my rights to privacy. I retain the right to withdraw this authorization in writing, except to the extent that actions have already been taken in reliance on this authorization. If I withdraw authorization, it will not affect information already released based upon this signed authorization.

This authorization will expire on: . If no date is entered, the authorization will remain in effect for the limited period necessary to complete post-exposure evaluation and any mandated reporting.

Acknowledgment: I acknowledge that I have read and understand the statements above and consent to the evaluation and release provisions as described.

Incident Reporting

I certify that the information I have provided on this Healthcare HAZ Profile is true and complete to the best of my knowledge. I understand that incomplete or false information may affect clinical care and workplace reporting obligations.

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