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Bloodborne Pathogens Post-Exposure Report

(Confidential)

About this Form

Form number: 230-33

Audience:  MCPS Staff

Last revised: July 2012

INSTRUCTIONS: This form is to be completed by the employee exposed to blood or other potentially infectious materials as soon as possible after the exposure and given to the examining physician. The employee shall forward a copy to the Employee and Retiree Service Center (ERSC) within five (5) days of the incident. COPY 2 should be sent to the Systemwide Safety Programs Unit, Department of Facilities Management.

Note: All medical records shall be kept confidential and may not be disclosed or reported without the employee’s express written consent to any person within or without the workplace, except as required by law, but may be reviewed and copied by the employee who is the subject of the file. Questions regarding the MCPS Bloodborne Pathogens program may be directed to the Systemwide Safety Programs Unit, 240-314-1070.

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