SOURCE INFORMATION Name of Source: _________________________ ______ Date of Birth: _________________ Previously diagnosed HIV positive? (Check) No________ Yes:_______ Date:_________ Previously diagnosed HBV positive? (Check) No________ Yes:_______ Date:_________ Previously diagnosed HCV positive? (Check) No________ Yes:_______ Date:_________ If there is not previous documentation of positive results of HIV and HBV blood testing, source content shall be obtained to test for HIV, HBV, and HCV.
Consent to HIV, HBV, HCV testing obtained? (Check) No: ______Yes: ______ Consent documentation must be attached.
If consent is not obtained, the exposed individual must establish that legally required consent cannot be obtained. When the source individual’s consent is not required by law, the source individual’s blood, if available, shall be tested and the results documented. Results of HIV Testing: Date:____________________ Results of HBV Testing: Date:____________________ Results of HCV Testing: Date:____________________
Source patient was referred to ______________________ (Physician) for HIV, HBV, and HCV blood testing. Results may be obtained from the above facility/physician.
I certify that the above information regarding the source individual has been documented and I will forward a copy of this form and other necessary records or documents to the above-named healthcare professional for their evaluation of the exposed employee. _________________________________ __________ Signature-Program Director Date
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Hodges University Student Handbook
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