Exposure Report

Employee Information

Employee Name(Required)

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Employee Email

Phone #

Employee Address(Required)

Street Address Address Line 2 City State ZIP Code

Call / Trip Information

Trip Number

Did you contact the on duty supervisor?(Required)

Yes

Which Supervisor did you contact?(Required)

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Supervisor Email

Exposure Source Information

Name of Patient(Required)

Patient Date of Birth

Nature of Incident(Required)

Location of Incident(Required)

Street Address Address Line 2 City State ZIP Code

Facility Receiving Patient(Required)

Final Receiving Facility

If different from the initial receiving facility (e.g., transfer to a trauma or specialty care facility).

Description of Communicable Disease Exposure

Type of Unprotected Exposure(Required)

Explain how and where the unprotected exposure took place.

Precautions Taken(Required)

Explain what precautions were taken, e.g., gloves, masks, eye protection, etc.

Date of Unprotected Exposure(Required)

Time of Unprotected Exposure(Required)

Instructions and Acknowledgment

Communicable Disease Exposure Report Instructions

Information for Emergency Response Personnel and Good Samaritans

Missouri Department of Health regulations contain detailed information concerning this form and the obligations of both the medical facility or coroner/medical examiner’s office and the emergency response personnel and/or good Samaritan.

WHO SHOULD FILE THIS FORM?

Any Missouri prehospital emergency response personnel (ERP) — EMS agency, law enforcement officer, firefighter, first responder, or good Samaritan — who has sustained a significant exposure should file this form either directly with the receiving medical facility or coroner/medical examiner’s office or the service’s designated officer who will determine whether to file the form with the medical facility to which the patient was initially taken. A significant exposure is defined by the Centers for Disease Control and Prevention as:

Any person-to-person contact in which a co-mingling of respiratory secretions (saliva and sputum) of the patient and ERP or good Samaritan may have taken place;
Transmittal of the blood or bloody body fluids of the patient onto the mucous membranes (mouth, nose, eyes) of the ERP or good Samaritan and/or into the breaks of the skin of the ERP or good Samaritan;
Transmittal of other body fluids (semen, vaginal secretions, amniotic fluids, feces, wound drainage, or cerebral spinal fluid) onto the mucous membranes or breaks in the skin of the ERP or good Samaritan;
Any non-barrier unprotected contact of the ERP or good Samaritan with mucous membranes or non-intact skin of the patient.

WHAT WILL HAPPEN WHEN THIS FORM IS FILED?

If appropriate personnel determine that the patient involved in the significant exposure has one of the specified diseases listed below and that the exposure described could transmit any of these diseases, you will be notified within 48 hours or as soon as possible after receipt of the patient’s diagnosis report. You will also be advised by either the designated officer or by the receiving medical facility’s personnel — depending on who directly contacted the ERP or good Samaritan — on what are the appropriate medical precautions and recommended follow-up. The specified diseases are: Pulmonary Tuberculosis, Hepatitis B and C, Human Immunodeficiency Virus infection (HIV) including Acquired Immunodeficiency Syndrome (AIDS), Rubella, Measles, Corynebacterium Diphtheria, Neisseria Meningitides, Hemorrhagic fevers including Lassa, Marburg, Ebola, Congo-Crimean, and others yet to be identified; plague (Yersinia pestis); and rabies.

NOTIFICATION

You will be notified within 48 hours or as soon as possible of the patient’s diagnosis report. The filing of this report does not mandate testing of the patient.

CONFIDENTIAL INFORMATION

Missouri Department of Health regulations require that the names of both the person who has suffered the communicable disease exposure and the person determined as having a communicable disease be kept confidential. A person who violates this confidentiality is guilty of a misdemeanor and is subject to fine or jail term.

For additional information regarding this form, the laws, or regulations, contact the Missouri Department of Health and Senior Services, Bureau of Emergency Medical Services, PO Box 570, Jefferson City, MO 65102 — (573) 751-6356.

Acknowledgment(Required)

I have read the instructions above and understand them.

Employee Signature(Required)

Date Signed(Required)