Form 57.205 Exposure to Blood/Body Fluids

Facility ID#:________________		Exposure Event#_________________________
*HCW ID#:_____________________
HCW Name, Last: ___________________    First:  ________________________   Middle:_____________
*Gender:      F       M       Other               *Date of Birth:   ____/_____/________
*Work Location: ___________________________
*Occupation ________________       If occupation is physician, indicate clinical specialty_________________
Section I – General Exposure Information
1. *Did exposure occur in this facility:   □ Y    □ N 1a. If No, specify name of facility in which exposure occurred: _____________________________
2. *Date of exposure: ____/___/_______                 3. *Time of exposure:______ □ AM  □ PM
4.   Number of hours on duty: ___________             5.  Is exposed person a temp/agency employee? □ Y  □ N
6. *Location where exposure occurred: ____________
7. *Type of exposure: (Check all that apply) □ 7a. Percutaneous: Did exposure involve a clean, unused needle or sharp object?          □ Y  □ N    (If  No, complete Q8, Q9, Section II and Section V–XI) □ 7b. Mucous membrane     (Complete Q8, Q9, Section III and Section V–XI) □ 7c. Skin: Was skin intact?  □ Y   □ N    □ Unknown (If  No, complete Q8, Q9, Section III &  Section V–XI) □ 7d. Bite   (Complete Q9, and Section IV–XI)
8. * Type of fluid/tissue involved in exposure: (Check one)
□ Blood/blood products	□ Body fluids: (Check one)
□ Solutions (IV fluid, irrigation, etc.): (Check one)	□ Visibly bloody
□ Visibly bloody	□ Not visibly bloody
□ Not visibly bloody
□ Tissue	If body fluid, indicate one body fluid type:
□ Other (specify) ____________	□ Amniotic		□ Saliva
□ Unknown	□ CSF		□ Sputum
9. *Body site of exposure: (Check all that apply)	□ Pericardial		□ Tears
□ Hand/finger        □ Foot	□ Peritoneal		□ Urine
□ Eye                    □ Mouth	□ Pleural		□ Feces/stool
□ Arm                   □ Nose	□ Semen		□ Other (specify)
□ Leg                    □ Other (specify) ____________	□ Synovial		_________________
	□ Vaginal fluid
Assurance of Confidentiality:  The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN:  PRA (0920-0666). CDC 57.205 (Front), v6.4                                                                                                                  Page 1 of 7

 

Section II – Percutaneous Injury
1. *Was the needle or sharp object visibly contaminated with blood prior to exposure? □ Y  □ N
2. Depth of the injury: (Check one)
□ Superficial, surface scratch	□ Deep puncture or wound
□ Moderate, penetrated skin	□ Unknown

Hollow-bore needle
□ Arterial blood collection device	□ Biopsy needle	□ Bone marrow needle
□ Hypodermic needle, attached to syringe	□ Hypodermic needle, attached to IV tubing	□ Unattached hypodermic needle
□ IV catheter – central line	□ IV catheter – peripheral line	□ Huber needle
□ Prefilled cartridge syringe	□ IV stylet	□ Spinal or epidural needle
□ Hemodialysis needle	□ Dental aspirating syringe w/ needle	□ Vacuum tube holder/needle
□ Winged-steel (Butterfly™ type) needle	□ Hollow-bore needle, type unknown	□ Other hollow-bore needle
Suture needle
□ Suture needle
Other solid sharps
□ Bone cutter	□ Bur	□ Electrocautery device
□ Elevator	□ Explorer	□ Extraction forceps
□ File	□ Lancet	□ Microtome blade
□ Pin	□ Razor	□ Retractor
□ Rod (orthopedic)	□ Scaler/curette	□ Scalpel blade
□ Scissors	□ Tenaculum	□ Trocar
□ Wire
Glass
□ Capillary tube	□ Blood collection tube	□ Medication ampule/vial/bottle
□ Pipette	□ Slide	□ Specimen/test/vacuum tube
Plastic
□ Capillary tube	□ Blood collection tube	□ Specimen/test/vacuum tube
Non-sharp safety device
□ Blood culture adapter	□ Catheter securement device	□ IV delivery system
□ Other known device (specify)	________________________
4. Manufacturer and Model:	_________________________

 

5. Did the needle or other sharp object involved in the injury have a safety feature? □ Y  □ N
5a. If yes, indicate type of safety feature: (Check one)   If No, skip to Q6.
□ Bluntable needle, sharp			□ Needle/sharp ejector
□ Hinged guard/shield			□ Mylar wrapping/plastic
□ Retractable needle/sharp			□ Other safety feature (specify) _______________
□ Sliding/gliding guard/shield			□ Unknown safety mechanism
5b. If the device had a safety feature, when did the injury occur? (Check one)
□ Before activation of the safety feature was appropriate			□ Safety feature failed, after activation
□ During activation of the safety feature			□ Safety feature not activated
□ Safety feature improperly activated			□ Other (specify) __________________
6. When did the injury occur? (check one)
□ Before use of the item	□ During or after disposal
□ During use of the item	□ Unknown
□ After use of the item before disposal
7. For what purpose or activity was the sharp device being used: (Check one)
Obtaining a blood specimen percutaneously
□ Performing phlebotomy	□ Performing a fingerstick/heelstick
□ Performing arterial puncture	□ Other blood-sampling procedure (specify)_________________________
Giving a percutaneous injection
□ Giving an IM injection	□ Placing a skin test (e.g., tuberculin, allergy, etc.)
□ Giving a SC injection
Performing a line related procedure
□ Inserting or withdrawing a catheter	□ Injecting into a line or port
□ Obtaining a blood sample from a central or peripheral I.V. line or port	□ Connecting an I.V. line
Performing surgery/autopsy/other invasive procedure
□ Suturing	□ Palpating/exploring
□ Incising	Specify procedure:_______________________
Performing a dental procedure
□ Hygiene (prophylaxis)	□ Oral surgery
□ Restoration (amalgam composite, crown)	□ Simple extraction
□ Root canal	□ Surgical extraction
□ Periodontal surgery
Handling a specimen
□ Transferring BBF into a specimen container	□ Processing specimen
Other
□ Other diagnostic procedure (e.g., thoracentesis)	□ Unknown
□ Other (specify)____________________________________________________

 

8. What was the activity at the time of injury? (Check one)
□ Cleaning room                                                               □ Collecting/transporting waste
□ Decontamination/processing used equipment	□ Disassembling device/equipment
□ Handling equipment	□ Opening/breaking glass container (e.g., ampule)
□ Performing procedure	□ Placing sharp in container
□ Recapping	□ Transferring/passing/receiving device
□  Other (specify)____________________________________________________
9. Who was holding the device at the time the injury occurred? (Check one)
□ Exposed person	□ No one, the sharp was an uncontrolled sharp in the environment
□ Co-worker/other person
10. What happened when the injury occurred? (Check one)
□ Patient moved and jarred device	□ Contact with overfilled/punctured sharps container
□ Device slipped	□ Improperly disposed sharp
□ Device rebounded	□ Other (specify)________________________
□ Sharp was being recapped	□  Unknown
□ Collided with co-worker or other person

 

Section III – Mucous Membrane and/or Skin Exposure
1. Estimate the amount of blood/body fluid exposure: (Check one)
□ Small (<1 tsp or 5cc)	□ Large (>¼ cup or 50cc)
□ Moderate (>1 tsp and up to ¼ cup, or 6–50cc)	□ Unknown
2. Activity/event when exposure occurred: (Check one)
□ Airway manipulation (e.g., suctioning airway, inducing sputum)	□ Patient spit/coughed/vomited
□ Bleeding vessel	□ Phlebotomy
□ Changing dressing/wound care	□ Surgical procedure (e.g., all surgical procedures including C-section)
□ Cleaning/transporting contaminated equipment	□ Tube placement/removal/manipulation (e.g., chest, endotracheal, NG, rectal, urine catheter)
□ Endoscopic procedures	□ Vaginal delivery
□ IV or arterial line insertion/removal/manipulation	□ Other (specify) ________________________________
□ Irrigation procedures	□ Unknown
□ Manipulating blood tube/bottle/specimen container
3. Barriers used by the worker at the time of exposure: (Check all that apply)
□ Face shield	□ Mask/respirator
□ Gloves	□ Other (specify) ________________________________
□ Goggles	□ No Barriers
□ Gown
Section IV - Bite
1. Wound description: (Check one)
□ No spontaneous bleeding	□ Tissue avulsed
□ Spontaneous bleeding	□ Unknown
2. Activity/event when exposure occurred: (Check one)
□ During dental procedure	□ Assault by patient
□ During oral examination	□ Other (specify) ________________________________
□ Providing oral hygiene	□ Unknown
□ Providing non-oral care to patient

 

Section V – Source Information
1. Was the source patient known?        □ Y  □ N
2. Was HIV status known at the time of exposure?     □ Y  □ N
3. Check the test results for the source patient (P=positive, N=negative, I=indeterminate, U=unknown, R=refused, NT=not tested)
Section VI – For HIV Infected Source
1. Stage of disease: (Check one)
□ End-stage AIDS	□ Other symptomatic HIV, not AIDS
□ AIDS	□ HIV infection, no symptoms
□ Acute HIV illness	□ Unknown
2. Is the source patient taking anti-retroviral drugs?       □ Y   □ N    □ U
2a. If yes, indicate drug(s):   _________ __________ ________ __________ ________ _________
3. Most recent CD4 count: _________mm3	Date: ____/______
4. Viral load: ____ copies/ml _____ undetectable	Date: ____/______
Section VII – Initial Care Given to Healthcare Worker
1. HIV postexposure prophylaxis:
Offered?   □ Y   □ N    □ U	Taken:  □ Y   □ N    □ U (If Yes, complete PEP form)
2. HBIG given?                     □ Y   □ N    □ U	Date administered: ____/___/_______
3. Hepatitis B vaccine given: □ Y   □ N    □ U	Date 1st dose administered: ____/___/_______
4. Is the HCW pregnant?       □ Y   □ N    □ U
4a. If yes, which trimester?   □ 1   □ 2    □ 3    □ U

Hepatitis B	P	N	I	U	R	NT
HBsAg
HBeAg
Total anti-HBc
Anti-HBs
Hepatitis C
Anti-HCV EIA
Anti-HCV supplemental
PCR-HCV RNA
HIV
EIA, ELISA
Rapid HIV
Confirmatory test

 

1.   Section VIII -  Baseline Lab Testing

1.    

        

        

        

1.   Section IX – Follow-up

1.   1. Is it recommended that the HCW return for follow-up of this exposure?   □ Y   □ N

1.        1a. If yes, will follow-up be performed at this facility?   □ Y   □ N

1.   Section X – Narrative

1.   In the worker’s words, how did the injury occur?

1.   Section XI - Prevention

1.   In the worker’s words, what could have prevented the injury?

Custom Fields
Label   ___________________   ___/___/___   ___________________   ___________   ___________________   ___________   ___________________   ___________   ___________________   ___________   ___________________   ___________   ___________________   ___________	Label    ___________________   ___/___/____    ___________________   ___________    ___________________   ___________    ___________________   ___________    ___________________   ___________    ___________________   ___________    ___________________   ___________
Comments

Was baseline testing performed on the HCW? □ Y   □ N  □ U      If Yes, indicate results
Test                                        Date                       Result					Test                   Date	Result
HIV EIA                               ___/___/______	P	N	I	R	ALT                ___/___/______	____IU/L
HIV Confirmatory                 ___/___/______	P	N	I	R	Amylase         ___/___/______	____IU/L
Hepatitis C  anti-HCV-EIA     ___/___/_______	P	N	I	R	Blood glucose ___/___/______	____mmol/L
Hepatitis C  anti-HCV-supp   ___/___/_______	P	N	I	R	Hematocrit     ___/___/______	____%
Hepatitis C  PCR HCV RNA    ___/___/_______	P	N	R		Hemoglobin    ___/___/______	____gm/L
Hepatitis B  HBs Ag              ___/___/______	P	N	R		Platelets         ___/___/______	____x109/L
Hepatitis B  IgM anti-HBc     ___/___/_______	P	N	R		Blood cells in Urine__/___/___	____#/mm3
Hepatitis B  Total anti-HBc   ___/___/_______	P	N	R		WBC               ___/___/_____	____x109/L
Hepatitis B  Anti-HBs           ___/___/_______	____ mIU/mL				Creatinine       ___/___/_____	____μmol/L
Result Codes: P=Positive, N=Negative, I=Indeterminate, R=Refused					Other:______ ___/___/_____	______

 

File Type	application/vnd.ms-powerpoint
File Title	Slide 1
Author	CDC
Last Modified By	ano3
File Modified	2010-08-05
File Created	2004-07-27

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