Fill and Sign the Most Unprotected Exposures Do Not Result in an Form

Form 350 Emergency Medical Service Provider Expo sure Report Form PLEASE PRINT OR TYPE Official Form 350 Revised 8/2012 Complete this form to document exposure to blood and/or other body fluids. Most unprotected exposures do not result in an infection, however, some people can be exposed to a disease an d not have any symptoms of illness. It is important that you document any significant exposure incident. Significant Exposure – EMS Provider Information Exposed Provider, use your last initial, first initial, last 4 digits of Social Security number for ID # ex. (ab1234) ID # _________ Employee Name ________________________________________ DOB _____/_____/_____ Sex ________ (Last) (First) (M) M or F Home Phone _______________ Work Phone ________________ Employer/Agency _ ______________________ Contact Person at Employment / Agency _________ _______________ Contact Phone ______________________ Date _____________________ Incident # ______________________ Mechanism of Exposure (check all that apply) Body Fluid Exposure Other Body Fluid w/Blood How Were You Exposed? Blood Saliva Splash in Eye Birth Fluids Urine Splash in Mouth or Nose Pericardial Fluids Feces Bite Pleural Fluid Pus Puncture w/Hollow-bore Needle Synovial Fluid Sputum Puncture Cut w/Other Sharp Implement Cerebrospinal Fluid Other Open Wound Semen Rash / Dermatitis Vaginal Secretions Abrasion What protective equi pment were you using at th e time of exposure? (check all that apply) Bag-Valve-Mask One Way Resu scitation Mouthpiece Paper Gown Gloves N-95 Mask Other Eye Protection Surgical Mask (Less than N-95 rating Source of Significant Exposure – Source Patient Information Source Patient Name ____________________________________ Phone Number _______________ Source Patient Address ____________ ______________________ (Street Address) DOB _____/ _____/_____ __________________________________ (City, State, Zip) Sex: M _____F_____ I hereby give my permission to the facility named below to draw and test my blood for any or all of the following: HIV Antibody, HBV/Surface Antigen and, HCV Antibody. I understand that the results of this testing are private information and will be confidential. I refuse to have my blood drawn and tested. I understand that a court order may be pursued to require me to have blood testi ng done. Source Patient (or responsible) Signature ____________________________________________ Date ______ /_ _____ /_ _____ Receiving Facility/Testing Laboratory Receiving Facility ________________________________________ _______Date Specimen(s) were obtained _____/_____/_____ Testing Laboratory _ _____________________________________________Date Specimen(s) were submitted _____ /____/_____ Did patient expire? Yes No Was the patient under the jurisdiction of the State Department of Corrections (Prisoner or Parolee)? Yes No Name of Person submitting report _________________________________________________________ Title ___ __________________________ Phone Number _________________ Date Report was submitted _____ /_____/_ _____ If onsite post exposure counseling is not available c ontact any of the following. http://www.ucsf.edu/hivcntr/Hotlines/PEPline.html 24/7 Or call (800) 537-1046. (801) 538-6096 or (800) FON-AIDS 8-5 M-F ( hospital clinicians may receive 24/7 help with PEP counseling by calling 1-888-448-4911) The Laboratory must report the test results of the source patien t testing to the EMS Agency/Employer Contact person listed abov e. * The EMS Agency/Employer must submit the Em ployer’s First Report of Injury/Illness (Form 122) when this form is completed by a n EMS Provider. State of Utah * Labor Commission * Division of Industrial Accidents 160 East 300 South * P.O. Box 146610 Salt Lak e City, UT 84114-6610 * Telephone: 801-530-6800 Fax: 801-530-6804 * Toll Free: (800) 530-5090 * www.laborcommission.utah.gov