HODGES UNIVERSITY DEPARTMENT OF DENTAL HYGIENE BLOODBORNE PATHOGEN EXPOSURE INCIDENT REPORT
This form must be completed following an exposure incident. When an exposure incident occurs, the exposed student or faculty member shall notify the Program Director and complete this form as soon as possible.
Name of Student/Faculty ________________________ Student/Faculty ID number ______________________
Have you received the HBV vaccination series? Yes or No (please circle)
Incident Description:
Date:
Time:
Exact Location:
Potentially Infectious Material Involved:
Source Individual:
Blood
Saliva
Vomit
Other (be specific)
Describe your activities as they relate to the exposure incident: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Continued on next page...
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Hodges University Student Handbook
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