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DcJ9XBsSJyDvqAgJdXfBRr5Unzo9UdZPnjBzWkqYZdVPWzpDWnhCvAIRbTexIhISXRNiZBMBXBsXE4GIjcN7umUqRHI

EVMS BBP Survey

Eastern Virginia Medical School - Occupational Health

This online form is to be completed by the employee when reporting a potential bloodborne pathogen exposure to occupational health. Please complete all available information as it is essential in helping us determine if there may be any need for post-exposure prophylaxis or whether other follow up will be appropriate. This will greatly facilitate the response. Thanks!

(*denotes required field)

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

Last Name:*	First Name:*
Employee or Student ID Number:*	Date of Birth:*

Cell or pager number:*

Email:*

What is your job or student category at EVMS (please check)?

* must provide value

Specialty Type:

* must provide value

Please specify:

Medical student

Physician assistant student

Surgical assistant student

Pathology assistant student

Other student

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Describe:

Please specify:

Describe:

Department:

* must provide value

Please specify:

Location of Exposure:

* must provide value

Please specify:

Date of Exposure:

* must provide value

M-D-Y

Time of Exposure:

* must provide value

H:M

Clinical or laboratory location where the exposure occurred:

* must provide value

Inpatient room

Emergency department

Operating room

Intensive or critical care unit

Labor and delivery

Outpatient clinic

Outpatient surgical center

Autopsy or pathology

Clinical or research lab

Other

Describe:

Was the source patient identifiable?

* must provide value

Patient Last Name:*	Patient First Name:*
Patient Date of Birth:*	Patient Medical Record Number:*

Check if the patient was known to be infected with any blood borne pathogen listed below:

* must provide value

HIV HCV HBV N/A

Was the patient otherwise at higher risk for HIV infection (check if factor is known/applicable)?

* must provide value

Men who have sex with men

Sex worker

Injecting drug user

Prisoner or incarcerated person

None of these apply or not known

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What type of exposure occurred (please specify):

* must provide value

Needlestick with suture needle

Needlestick with hollow bore needle

Scalpel

Splash of body fluid to mucous membrane (e.g., conjunctiva, nose, mouth)

Splash of body fluid to non-intact skin (e.g., with superficial cut or abrasion)

Other sharp item

N/A

Describe:

What patient body fluid was involved in the exposure?

* must provide value

Blood or blood products

Vomit

Sputum

Saliva

CSF

Peritoneal fluid

Pleural fluid

Amniotic fluid

Urine

Other

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Describe:

Was the body fluid visibly contaminated with blood?

* must provide value

What was the worker or student's exposed body part?

* must provide value

Describe:

Please describe the exposed body part:

Expand

Did the sharp item penetrate?

* must provide value

What was the immediate care of the injured or exposed site? Describe. (e.g., degloved, washed with soap and water, flushed eye, etc.)

* must provide value

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Were safer medical devices or PPE in use (please check all that apply)?

* must provide value

Gloves

Face shield

Goggles or wrap-around protective glasses

Eyeglasses (not protective if not wrap-around)

Surgical mask

Gown

Retractable needle or scalpel blade

Needle sheath

Not applicable

Based on your responses, your exposure might be a potential risk for infection with a blood borne pathogen.

Utilize the EVMS exposure packet instructions with the charge nurse to have the exposure labs drawn on the source patient. If not at Sentara Healthcare, CHKD or Bon Secours please follow your facility's Bloodborne Pathogen Exposure Protocols.
You will also be required to complete the two required exposure forms in the packet and return them to Occupational Health within 24 hours of your exposure. If these forms are not available to you, Occupational Health can email them to you upon request.
If AFTER normal work hours (non-holiday, M-F, 8am to 4:30pm) and you have not had a contact from the on call team, page 757-554-1192. On Call Physicians may be attending to urgent patient care needs. If you do not receive a call back in 20 minutes, you may call 757-388-9751 to directly reach On Call Physicians.

Labs drawn on the source patient are drawn as routine except for the HIV lab which is drawn as "STAT." The on-call provider will call you with the HIV results and advise if Post-Exposure Prophylaxis (PEP) is indicated.

If PEP is indicated and this occurs after hours, you may need to also be evaluated in the Emergency Room in order to be started on PEP. If PEP is indicated and this occurs during normal business hours, a prescription will be called in for you to the Outpatient Pharmacy at SNGH. You have up to 72 hours to start PEP. Routine lab results (HBV, HCV) on the source patient will be called to you by Occupational Health during normal business hours once they are made available.

Based on your responses, your exposure might be a potential risk for infection with a blood borne pathogen.

Utilize the EVMS exposure packet instructions with the charge nurse to have the exposure labs drawn on the source patient. If not at Sentara Healthcare, CHKD or Bon Secours please follow your facility's Bloodborne Pathogen Exposure Protocols.
You will also be required to complete the two required exposure forms in the packet and return them to Student Health within 24 hours of your exposure. If these forms are not available to you, Student Health can email them to you upon request.
If AFTER normal work hours (non-holiday, M-F, 8am to 4:30pm) and you have not had a contact from the on call team, page 757-554-1192. On Call Physicians may be attending to urgent patient care needs. If you do not receive a call back in 20 minutes, you may call 757-388-9751 to directly reach On Call Physicians.

If PEP is indicated and this occurs after hours, you may need to also be evaluated in the Emergency Room in order to be started on PEP. If PEP is indicated and this occurs during normal business hours, a prescription will be called in for you to the Outpatient Pharmacy at SNGH. You have up to 72 hours to start PEP. Routine lab results (HBV, HCV) on the source patient will be called to you by Student Health during normal business hours once they are made available.

Based on your responses, your exposure might be a potential risk for infection with a blood borne pathogen.

Utilize the EVMS exposure packet instructions with the charge nurse to have the exposure labs drawn on the source patient. If not at Sentara Healthcare, CHKD or Bon Secours please follow your facility's Bloodborne Pathogen Exposure Protocols.
You will also be required to complete the two required exposure forms in the packet and return them to Occupational Health within 24 hours of your exposure. If these forms are not available to you, Occupational Health can email them to you upon request.
If AFTER normal work hours (non-holiday, M-F, 8am to 4:30pm) and you have not had a contact from the on call team, page 757-554-1192. On Call Physicians may be attending to urgent patient care needs. If you do not receive a call back in 20 minutes, you may call 757-388-9751 to directly reach On Call Physicians.

Based on your responses, your exposure might be a potential risk for infection with a blood borne pathogen.

Utilize the EVMS exposure packet instructions with the charge nurse to have the exposure labs drawn on the source patient. If not at Sentara Healthcare, CHKD or Bon Secours please follow your facility's Bloodborne Pathogen Exposure Protocols.
You will also be required to complete the two required exposure forms in the packet and return them to Student Health within 24 hours of your exposure. If these forms are not available to you, Student Health can email them to you upon request.
If AFTER normal work hours (non-holiday, M-F, 8am to 4:30pm) and you have not had a contact from the on call team, page 757-554-1192. On Call Physicians may be attending to urgent patient care needs. If you do not receive a call back in 20 minutes, you may call 757-388-9751 to directly reach On Call Physicians.

If PEP is indicated and this occurs after hours, you may need to also be evaluated in the Emergency Room in order to be started on PEP. If PEP is indicated and this occurs during normal business hours, a prescription will be called in for you to the Outpatient Pharmacy at SNGH. You have up to 72 hours to start PEP. Routine lab results (HBV, HCV) on the source patient will be called to you by Student Health during normal business hours once they are made available.

Based on your responses, you do NOT have an "at risk exposure" which is of concern for transmission of any blood borne pathogen.

Please resume your usual activities and continue standard precautions, appropriate use of PPE, and safe injection practices.

Based on your responses, you do NOT have an "at risk exposure" which is of concern for transmission of any blood borne pathogen.

Please resume your usual activities and continue standard precautions, appropriate use of PPE, and safe injection practices.

If the patient is known HIV positive, please contact the call the EVMS exposure phone at (757) 388-9751 to have the on-call provider review your exposure information and provide you with further instructions. If the physician does not answer, please call back in 10 minutes as the physician may be helping another patient.
PEP is indicated and this occurs during normal business hours, a prescription will be called in for you to the Outpatient Pharmacy at SNGH.
You have up to 72 hours to start PEP. Routine lab results (HBV, HCV) on the source patient will be called to you by Occupational Health during normal business hours once they are made available.

Name of student/resident completing this form?

Lab called?

Yes No

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Outcome of HIV test:

Positive Negative

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.