FORM 6 EXPOSURE INCIDENT FOLLOW-UP

FORM 6

ELKHORN PUBLIC SCHOOLS

EXPOSURE INCIDENT FOLLOW-UP

Employee:

Employee Social Security Number:

Exposure Incident
Date:

Exposure Incident Form Completed
Date:

Exposure Incident Form to Administration
Date:

Medical Evaluation
Date:

Information Sent to Health Care Professional
Date:

Employee Medical Tests Completed
Date:

Source Individual Medical Tests Completed
Date:

Written Report From Health Care Provider Received
Date:

Hepatitis B Vaccine Given
Date:

Exposure Incident Reviewed
Date: