Health Care Provider Instructions

This employee is being referred for your evaluation of an exposure
incident to blood or another potentially infectious material. This
referral is to be performed under the provisions of the OSHA Bloodborne
Pathogen Standard (29 CFR 1910.1030). A copy of this standard is
attached. Several items included in the OSHA standard deserve your close
attention.

1.  Under the OSHA standard, the following bodily fluids are considered
    potentially infectious: blood, semen, vaginal secretions,
    cerebrospinal fluid, synovial fluid, pleural fluid, pericardial
    fluid, peritoneal fluid, amniotic fluid, saliva (in dental
    procedures), and any body fluid visibly contaminated with blood.

2.  The exposed employee's blood should be collected as soon as feasible
    after consent is obtained and tested for HBV and HIV status.

3.  If the employee gives consent for baseline blood collection, but
    does not give consent for HIV serological testing at the time of
    collection, the blood sample should be stored for 90 days. If within
    90 days of the exposure incident, the employee elects that the
    baseline sample be tested, such testing should be performed.

4.  Postexposure prophylaxis is to be given according to the guidelines
    of the U.S. Public Health Service. Optimal use of these
    recommendations requires knowledge of the HBV status of the source
    and the exposed individual.

5.  OSHA requires that you submit a report of the post-exposure
    evaluation. A form for this purpose is attached.

**Health Care Provider Report of Post‑Exposure Evaluation**

Employee name:

Date of office visit:

Health Care Facility Address:

Health Care Facility Telephone:

As required under the OSHA Bloodborne Pathogen Standard:

-   The employee named above has been informed of the results of the
    post-exposure medical evaluation.

-   The employee named above has been told about any medical conditions
    resulting from exposure to blood or other potentially infections
    materials which require further evaluation or treatment.

(Printed/Typed Name of Health Care Provider) Signature of Health Care
Provider/Date

**Treatment Protocol Table.**

**Recommendations for hepatitis B prophylaxis following exposure
incident.**[^1]

+------------+---------------------+------------+---------------------+
|            | Treatment when      |            |                     |
|            | source is found to  |            |                     |
|            | be                  |            |                     |
+------------+---------------------+------------+---------------------+
| Exposed    | HBSAG positive      | HBSAG      | Unknown or not      |
| person     |                     | negative   | tested              |
+------------+---------------------+------------+---------------------+
| Un         | Administer HBIG x   | Initiate   | Initiate hepatitis  |
| vaccinated | 1? and initiate     | hepatitis  | B vaccine H         |
|            | hepatitis B vaccine | B vaccine  |                     |
|            | H                   | H          |                     |
+------------+---------------------+------------+---------------------+
| Previously | Test exposed person | No         | No treatment        |
| vaccinated | for anti-HB's^2^    | treatment  |                     |
|            |                     |            |                     |
| Known      | 1\. If adequate, no |            |                     |
| responder  | treatment           |            |                     |
|            |                     |            |                     |
|            | 2\. If inadequate,  |            |                     |
|            | hepatitis B vaccine |            |                     |
|            | booster dose        |            |                     |
+------------+---------------------+------------+---------------------+
| Known      | HBIG x 2 or HBIG x  | No         | No treatment        |
| no         | 1, plus 1 dose of   | treatment  |                     |
| nresponder | hepatitis B vaccine |            |                     |
+------------+---------------------+------------+---------------------+
| Response   | Test exposed person | No         | Test exposed person |
| unknown    | for anti‑HB^2^      | treatment  | for anti‑HB^2^      |
|            |                     |            |                     |
|            | 1\. If inadequate   |            | 1\. If inadequate,  |
|            | HBIG x 1, plus      |            | hepatitis B vaccine |
|            | hepatitis B vaccine |            | booster dose        |
|            | booster dose        |            |                     |
|            |                     |            | 2\. If adequate, no |
|            | 2\. If adequate, no |            | treatment           |
|            | treatment           |            |                     |
+------------+---------------------+------------+---------------------+

^1^ Hepatitis B immune globulin (HBIG) dose 0.06 ml/kg intramuscularly.

^2^ Adequate anti‑HB's is 10 milli‑international units. Hepatitis B
vaccine dose‑see Table 1.

[^1]: