Get Ma Unprotected Exposure Form 2000-2025

Completing the MA Unprotected Exposure Form online is an important step for prehospital emergency care workers who may have experienced an unprotected exposure to a patient's blood or bodily fluids. This guide provides clear and supportive instructions to help you navigate each section of the form effectively.

Follow the steps to complete your form online successfully.

1. Press the ‘Get Form’ button to access the MA Unprotected Exposure Form and open it in your document management system.
2. Begin by entering today’s date and the incident date in the designated fields. Ensure that the dates are accurate, as this information is crucial for record-keeping.
3. Fill in the transporting ambulance service, including the address and telephone number for the Designated Infection Control Officer (DICO). If available, use typed information for clarity.
4. Complete the patient information section, including name and date of birth (DOB). Make sure to provide accurate details.
5. Provide information about the incident location and type of incident, such as medical or trauma.
6. Enter details about the receiving facility and the ambulance trip report number, which is essential for tracking purposes.
7. In the rescuer information section, include your name, date of birth, address, and contact numbers. Be certain to provide both day and evening phone numbers.
8. Check the appropriate box(es) to indicate the exposure route (e.g., needlestick, bite) and the exposure type (e.g., blood, saliva). Select all that apply.
9. List the precautions you took during the incident by checking the relevant box(es), including items like masks or gloves.
10. Describe the nature of the unprotected exposure in detail. Utilize the provided space and attach additional pages if necessary to explain the circumstances.
11. Detail the steps you took to minimize the exposure. This may include actions such as washing contaminated skin or other cleaning measures.
12. Sign and date the form in the designated signature field. Ensure that the form is complete, then save your changes, and download a copy for your records.

Complete your MA Unprotected Exposure Form online today for timely processing.