607     POST EXPOSURE EVALUATION FORM    

SECTION 1 - EMPLOYEE TO COMPLETE (attach to incident report) 

Name_____________________________Job__________________________________

Date and time of incident__________________________________________________

 Area where you were working at the time of injury.  Give a brief description of exposure incident.

________________________________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________

Results of source individual's blood testing, if available: ________________________

Hepatitis B Vaccination Status (please circle one):      Vaccinated           Not Vaccinated

Dates of Vaccine Doses 

First Dose ________         Rationale:_______________________________________ 

Second Dose ________   ________________________________________________

Third Dose ________        ________________________________________________

Employee Signature __________________________________Date________________

Section 2

HEALTH CARE PROFESSIONAL'S WRITTEN OPINION

Check only one: 

___     HBV vaccination indicated for this employee, vaccination not received.

___     HBV vaccination not indicated for this employee, vaccination not received.

___     HBV vaccination indicated for this employee, vaccination received.

Check after completion: 

___     Employee has been informed of evaluation results.