Healthcare OSHA Questionnaire

HEALTHCARE OSHA QUESTIONNAIRE

Purpose: This OSHA Questionnaire collects patient and exposure-related information necessary for occupational health evaluation, infection control screening, and compliance with workplace safety reporting requirements. The information provided will be used to assess risk of exposure to bloodborne pathogens and other workplace hazards, determine need for testing or treatment, and to document training, immunization, and incident records. Completion of this form is mandatory for clinical evaluation following known or suspected workplace exposures. False statements may result in disciplinary or administrative action.

Patient Information

Date of Birth:    Gender:    Medical Record / Employee ID:

Insurance / Employer

Medical History & Current Status

OSHA Exposure Screening

Within the last 30 days, has the patient experienced any occupational exposure to blood, body fluids, or other potentially infectious materials? Yes No

Needlestick or sharp object injury requiring evaluation? Yes No

Symptoms Screening (past 14 days)

Check all that apply:

Fever or chills New or worsening cough Sore throat Shortness of breath Nausea or vomiting

Immunization & Testing

Hepatitis B vaccination status: Vaccinated Not vaccinated/Declined

Influenza vaccination this season: Yes No

COVID-19 vaccination series complete: Yes No

TB / Respirator Information

Currently assigned to respirator use or airborne isolation duties? Yes No

Work Restrictions / Follow-Up

Are work restrictions currently required or recommended by treating clinician? Yes No

Training & Acknowledgments

By signing below, I certify that the information provided is true and accurate to the best of my knowledge. I understand this information may be used to determine appropriate clinical evaluation, testing, treatment, work restrictions, and mandatory reporting to my employer or public health authorities as required by occupational safety laws. I authorize release of relevant medical information to my employer for purposes of workplace follow-up and OSHA-required recordkeeping. This authorization will expire on the date entered below unless revoked in writing prior to that date.

Additional Notes / Clinician Use

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