Get Emergency Medical Service Provider Exposure Report Form - Laborcommission Utah

Completing the Emergency Medical Service Provider Exposure Report Form is a vital step in documenting potential exposure to blood and body fluids. This guide will help you navigate the process of filling out the form accurately and efficiently online.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the exposed provider's information. Enter the employee's name, date of birth, and sex, ensuring accuracy for identification purposes.
3. Provide the contact details including home and work phone numbers along with the employer or agency name.
4. Input the contact person's name at the employment agency and their phone number for follow-up communication.
5. Document the date of the incident and the corresponding incident number, which is crucial for record-keeping.
6. Identify the mechanism of exposure by checking all applicable options related to body fluid exposure, such as blood, saliva, or other fluids.
7. Describe how the exposure occurred by selecting one or more methods, like 'splash in eye' or 'puncture with hollow-bore needle.'
8. Indicate the protective equipment used at the time of exposure by checking all relevant items, such as gloves or masks.
9. Fill in the source patient’s information, including their name, phone number, address, date of birth, and sex.
10. Choose whether the source patient gives permission for blood testing or refuses it, and ensure they sign and date the form.
11. Complete the receiving facility and testing laboratory details, including specimen collection and submission dates.
12. Confirm whether the source patient expired and if they were under the jurisdiction of the State Department of Corrections.
13. Document the name, title, phone number, and submission date of the person completing the report.
14. Finally, once all fields are completed accurately, ensure to save your changes, and download, print, or share the form as needed.

Start filling out your Emergency Medical Service Provider Exposure Report Form online now.