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BLOODBORNE PATHOGENS POST-EXPOSURE MEDICAL EVALUATION AND FOLLOW-UP CONSENT/DECLINATION FORM Occupational exposure to blood or other potentially infectious materials presents a risk to the exposed employee of acquiring hepatitis B virus (HBV) infection and/or human immunodeficiency virus (HIV). The City of Woodburn offers at no cost to any BBP exposed employee a post-exposure medical evaluation and follow-up from a licensed healthcare professional, including post-exposure prophylaxis, when medically indicated, as recommended by the U.S. Public Health Service, counseling, and evaluation of reported illnesses. The City of Woodburn will receive a written opinion from the licensed healthcare professional within fifteen (15) days of the completion of the evaluation. The healthcare professional’s opinion shall be limited to whether hepatitis B vaccination is indicated for the exposed employee and if the employee has received such vaccination. The professional’s written opinion with respect to medically evaluating the exposed employee, shall be limited to the following: 1) that the exposed employee has been informed of the results of the evaluation; and 2) that the exposed employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment. ALL OTHER FINDINGS AND DIAGNOSES SHALL REMAIN CONFIDENTIAL AND SHALL NOT BE INCLUDED IN THE WRITTEN OPINION. CONSENT FORM I, understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection and/or human immunodeficiency virus (HIV)-both serious illnesses. I hereby consent to a post-exposure medical evaluation and follow-up as described above. Exposed Individual Signature Witness Signature Exposed Individual’s Social Security Number Affiliation Date Date DECLINATION FORM I, understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection and/or human immunodeficiency virus (HIV)-both serious illnesses. However, I hereby decline post-exposure medical evaluation and follow-up. Exposed Individual Signature Witness Signature Exposed Individual’s Social Security Number Affiliation Date Date Note: Exposed Employee must complete either the Consent Form or Declination Form, but not both.