POST-EXPOSURE EVALUATION AND FOLLOW-UP FORM
CSUCI Bloodborne Pathogen Exposure Program
1. As part of my employment with California State University Channel Islands, I may have been
exposed to blood or other potentially infectious materials on the following date:
2. The means of exposure was:
3. Name and address of the source individual:
4. A Supervisor's Injury or Illness Report was filed with Human Resources on:
Exposure Incident Report Form has been completed (copies forwarded to EHSRM and Human Resources).
Source individual's blood has been tested (provided consent was obtained).
Exposed employee has been notified of the test results.
I accept Hepatitis B Immune Globulin treatment.
I accept the Hepatitis B vaccination series.
I do not consent to baseline blood collection.
I consent to baseline blood collection but do not consent to any testing at this time. I understand that
the blood sample shall be perserved for at least 90 days. If, within 90 days of the exposure incident, I
elect to have the samples tested for either HBV and/or HIV, such testing shall be done as soon as feasible.
I consent to baseline blood collection and HBV serological testing.
I decline Hepatitis B Immune Globulin treatment.
I decline the Hepatitis B vaccination series.
EMPLOYEE SIGNATURE
NAME (PLEASE PRINT)
PHYSICIAN SIGNATURE
DATE
DATE
PROGRAM OR AREA OF WORK
Copies to Environmental Health, Safety, Risk Mangement; Human Resources; Attending Physician
I further undestand that as a result of this exposure I may require evaluation or treatment due to the
potential risk of acquiring Hepatitis B virus, HIV or other bloodborne infection. I was offered and
encouraged to have a confidential medical evaluation and follow up, and have been given the
opportunity to be vaccinated with the Hepatitis B vaccine and/or Hepatitis B Immune Globulin at no
charge to myself.
Please check the following that apply:
