HENDERSONVILLE EMERGENCY SERVICES - INFECTIOUS DISEASE EXPOSURE RECORD      
                                                                           CONFIDENTIAL REPORT            
                       
DATE OF EXPOSURE_______________________________    TIME OF EXPOSURE___________________________    
                       
EMPLOYEE INVOLVED____________________________________LAST 4 DIGITS OF SOCIAL__________________    
                       
SOURCE NAME__________________________________________________________________________________    
                       
SOURCE ADDRESS_______________________________________________________________________________    
                       
SOURCE TAKEN TO HOSPITAL_______________   JAIL________________ OTHER (SPECIFY)__________________    
                       
HOSPITAL NAME________________________________________________________________________________    
                       
BRIEFLY DESCRIBE WHAT HAPPENED_______________________________________________________________    
_______________________________________________________________________________________________    
_______________________________________________________________________________________________    
_______________________________________________________________________________________________    
_____________I have been advised of the availability of Post Exposure Medical Evaluation per OSHA      
                           requirements and am hereby requesting this be provided at no cost to me.  I understand    
                           that I will file a Workman's Compensation claim on my behalf and I authorize release      
                           of any necessary information to the Workman's Compensation carrier and the      
                           treating medical personnel to conduct this evaluation and to process any claim.      
                       
_____________I have been advised of the availability of Post Exposure Medical Evaluation per OSHA      
                          requirements and hereby decline Post Exposure Evaluation for the following reasons      
       (check at least one):                
       ____________ I don't believe I was "exposed" per OSHA definitions.        
       ____________I don't want the Post Exposure Evaluation.          
                       
_____________________________________________     ________________________________________________    
Employee's Signature and Date     Supervisor's Signature and Date        
                       
_____________________________________________     ________________________________________________    
Personnel Director's Signature     Date Received by Personnel        
                       
CONFIDENTIAL REPORT FOR USE BY THE FOLLOWING INDVIDUALS ONLY:  EMPLOYEE, IMMEDIATE      
SUPERVISOR, PERSONNEL OFFICIAL, HR COORDINATOR, WORKMAN'S COMPENSATION CARRIER, AND       
TREATING MEDICAL PERSONNEL.  FILE IN SEALED ENVELOPE MARKED "CONFIDENTIAL - MEDICAL RECORDS".    
                       
It is the employee's responsibility to notify the City of Hendersonville of any potential exposure      
incident.  Submit this form directly to the Human Resources Manager in a sealed envelope        
marked "Confidential" along with the First Report of Work Injury or Illness forms.        
                       
IF LEAVING FORMS IN OVERNIGHT DROP BOX, PLEASE REMEMBER TO CALL HR AT 615-264-5314 AND      
LEAVE MESSAGE REGARDING FORMS OR EMAIL personnel@hvilletn.org for notification.        
                                   TO BE GIVEN TO SOURCE AND/OR DESIGNEE AS APPROPRIATE          
NOTE:  OSHA Regulations (Standard 1910.1030) requires us to request the following.  Your consent is      
not mandatory.  We can only request your cooperation to help u help us protect our employees who may      
have accidentally suffered an occupational exposure to your blood or other body fluids.          
                       
                                             CONSENT TO HIV AND/OR HBV ANTIBODY TESTING          
                       
I understand one or more Hendersonville Public Safety employees have reported an occupational      
exposure to either my blood and/or other body fluids as a result of their rendering assistance to me.      
                       
I further understand:                    
                       
1 That per OSHA regulations, the City of Hendersonville is obligated to make immediately      
  available to the employee:                
                       
    a.  Documentation and identification of the source individual        
    b.  Results of the source individuals blood testing, if available        
    c.  If consent is not obtained, a statement verifying such          
                       
2 Results of the testing shall be made available to the exposed employee, and the employee      
  shall be informed of applicable laws and regulations concerning disclosure of the identity      
  and infectious status of the source individual.            
                       
3 The City of Hendersonville will pay for the test and will make arrangements for the test.      
                       
4 Results of this test will be kept strictly confidential and released only to those individuals      
  on a need to know basis (which may include medical professionals, Personnel Official,      
  HR Coordinator and Worker's Comp employees.            
                       
5 The potential side effects of this testing are those encountered during the routine procedure    
  of obtaining blood specimens.  The minor complications may include discomfort from the      
  needle stick, and slight bruising, bleeding, or soreness at the site where the blood was       
  obtained.                    
                       
_____________________I have read the above and I hereby give my consent to have my blood tested for    
    antibody to HIV and/or HIV and agree to the limited release of the results to      
    only those individuals who have a need to know with the understanding this      
    information will be kept in the strictest confidentiality.          
                       
_____________________I have read the above and I refuse to consent to this test.        
                       
__________________________________________                     __________________________________________    
Signature         Agent, parent or guardian         
          (Indicate relationship to individual)      
__________________________________________ __________________________________________    
Witness         Date