New Jersey Department of Health

PEOSH Unit

REQUEST FOR SOURCE INDIVIDUAL EVALUATION

Dear (Emergency Room Medical Director, Infection Control Practitioner):

During a recent transport of a patient to your facility, one of our pre-hospital care providers was involved in an event that may have resulted in exposure to Bloodborne Pathogens.

I am asking you to perform an evaluation of the source individual who was transported to your facility. Given the circumstances surrounding this event, please determine whether our pre-hospital care worker is at risk for infection and/or requires medical follow-up.

Attached is a “Documentation and Identification of Source Individual” form which was initiated by the exposed worker. Please complete the source individual section and communicate the findings to the designated medical provider.

The evaluation form has been developed to provide confidentiality assurances for the patient and the exposed worker concerning the nature of the exposure. Any communication regarding the findings is to be handled at the medical provider level.

We understand that information relative to human immunodeficiency virus (HIV) and AIDS has specific protections under the law and cannot be disclosed or released without the written consent of the patient. It is further understood that disclosure obligates persons who receive such information to hold it confidential.

Thank you for assistance in this very important manner.

Sincerely,

________________________________

CONFIDENTIAL

DOCUMENTATION AND IDENTIFICATION

OF SOURCE INDIVIDUAL

Name of Exposed Employee:
Name of Medical Provider Who Should be Contacted:
Phone Number of Medical Provider:
Incident Information
Date:
Individual Who is the Source of the Exposure:
Name or Medical Record Number:
Nature of the Incident
Contaminated Needle Stick Injury
Blood or Body Fluid Splash onto Mucous Membrane or Non-Intact Skin
Other:
Report of Source Individual Evaluation
Chart Review By:	Date:
Source Individual Unknown-Researched By:	Date:
Testing of Source Individual’s Blood: Consent: Obtained Refused
Check one:
Evaluation of the source individual reflected no known exposure to Bloodborne Pathogens.
Evaluation of the source individual reflected known exposure to Bloodborne Pathogens.
Evaluation of the source individual reflected possible exposure to Bloodborne Pathogens and medical follow‑up is recommended.
Identification of source individual infeasible or prohibited by state or local law.
State why identification is infeasible:
Name of Person Completing Report:	Date:
Note:	Report the results of the source individual’s blood test to the medical provider named above who will inform the exposed employee. Do not report blood test findings to the employer.
HIV-related information cannot be released without the written consent of the source individual.

OCC-3

NOV 13

OCC-

OCT 08	29 CFR 1910.1030, OSHA’s Bloodborne Pathogens Standard, in paragraph (h)(5), requires an employer to establish and maintain a Sharps Injury Log for recording all percutaneous injuries in a facility occurring from contaminated sharps. The purpose of the Log is to aid in the evaluation of devices being used in healthcare and other facilities and to identify problem devices or procedures requiring additional attention or review. This log must be kept in addition to the injury and illness log required by 29 CFR 1904. The Sharps Injury Log should include all sharps injuries occurring in a calendar year. The log must be retained for five years following the end of the year to which it relates. The Log must be kept in a manner that preserves the confidentiality of the affected employee.

OCC-3, Request for Source Individual Evaluation

occ-3, request for source individual evaluation, PEOSH, occupational, OCC

ewhite

2009-02-24

NJDOH