Hospital Treating Physician

The Post-Exposure Evaluation and Follow-up Plan was developed to assist Miami University comply with adopted regulations set forth in federal Occupational Safety and Health Administration (OSHA) standards addressing bloodborne pathogens exposures involving our employees. The information sheets and forms contained in this plan will assist you in completing your evaluation and document our collective compliance efforts without disclosing employee medical information.

Employee Disposition

Before proceeding with any post-exposure evaluation or follow-up procedure, please verify that our employee has signed all of the appropriate disposition forms which indicate their consent or declination for each process or action. If a Miami University employee declines a post-exposure evaluation and follow-up procedures: Indicate their decision on the second page of the BBP Post-Exposure Medical Form & Incident Report, and forward to the Director of Miami University Student Health Service, Medical Records Section, 421 Campus Avenue, Oxford, OH 45056. Please verify that the employee has signed the form. If a Miami University employee consents to post-exposure evaluation and follow-up procedures: Have the employee read and sign the appropriate consent forms described below. The employee should have completed the Employee Information, Incident Details, Incident Description, and the Witnesses sections on the BBP Post-Exposure Medical Form & Incident Report. Proceed with completing the BBP Post-Exposure Medical Form & Incident Report and with your post-exposure evaluation. Schedule follow-up procedures as necessary.

Forms and Information

The following is a list of forms and information included in this packet and a brief explanation for each:

BBP Post-Exposure Medical Form & Incident Report (PDF 150KB)

This form is designed to document details related to the incident and generalized decisions regarding the evaluation, testing of the exposed employee and, if applicable, testing of the source.

Consent/Declination for Medical Evaluation and Follow-up (PDF 48KB)

A written consent (or declination) to medical procedures conducted by a licensed healthcare professional including prophylaxis, counseling, and evaluation of reported illnesses.

Consent/Declination for Blood Testing (PDF 56KB)

A written consent (or declination) to baseline blood sampling conducted by a licensed healthcare professional for any or all of the following identified on the form: Hepatitis B (HBV); Hepatitis C (HCV); and human immunodeficiency virus (HIV).

Hepatitis B Vaccination Program Consent/Declination Form (PDF 86KB)

If the treating physician determines that our employee should begin the Hepatitis B vaccination series, our employee must first read and sign this consent form. Our employee has the option to decline the vaccination series as provided on the form.

Ohio Department of Health Informed Consent to HIV Antibody Test (PDF 59KB)

Similar to the Consent/Declination for Blood Testing form, a written consent must be provided prior to testing for HIV.

Notice of Confidentiality – Source Individual’s Medical Information (PDF 45KB)

An employee involved in an exposure incident may receive medical information about the source individual. This form serves as an agreement by the employee to keep that information confidential.

Consent for Blood Collection and Testing of Source Individual (PDF 125KB)

A written consent by the source individual for blood collection to test for Hepatitis B (HBV and human immunodeficiency virus (HIV).

Medical Release and Authorization (PDF 109KB)

Standard form that will permit authorized Miami University staff access to information related to the exposure incident for investigative or recordkeeping purposes relative to regulatory compliance.

Physician’s Written Opinion to Miami University (PDF 194KB)

Paragraph (f)(5) of the OSHA Bloodborne Pathogens standard requires that Miami University obtain a copy of the evaluating healthcare professional's written opinion within 15 days of the completion of the evaluation. The Physician’s Written Opinion is a sample opinion letter.

Sharps Injury Form: Needlestick Report

The nursing supervisor or designee is responsible for completing this form when an employee experiences an occupational exposure incident involving a sharp. Send completed form to EHSO for reporting to the Public Employment Risk Reduction Program. This is the ONLY form to send to EHSO.

Hepatitis B Virus and Vaccine Information Sheet

HIV and AIDS Fact Sheet

Bloodborne Pathogens Standard

Post-Exposure Evaluation and Follow-up Process

If follow-up is necessary: make every effort to refer our employee to the Miami University Student Health Service for additional follow-up treatment and review of laboratory results. Please return all of the ORIGINAL forms in this packet to:

Miami University Student Health Service
Medical Records Section
421 S. Campus Avenue
Oxford, OH 45056