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Healthcare Professionals Writen Opinion for Post-Exposure EvaluaƟon and Follow-up DirecƟons: This form needs to be filled out by the healthcare professional following an exposure incident and returned to the employer. The employer will maintain a copy of this form PLUS give the exposed employee a copy within 15 days. The employee has been informed of the results of the evaluaƟon. Yes:☐ No:☐ The employee has been told about any medical condiƟons resulƟng from exposure to blood or other potenƟally infecƟous materials which require further evaluaƟon or treatment. Yes:☐ No:☐ Healthcare Provider’s Signature: Date: The blood or body-fluid source individual will be asked to consent to having their blood collected and tested for HBV and HIV. For our clients under 18 years of age, if they are the source individual, their legal guardian will be asked to give consent for tesƟng. The following informaƟon must be recorded: Name: Blood Taken: Yes:☐ No:☐ Date taken: Writen/Oral Consent Given For: HBV TesƟng Yes: ☐ No: ☐ HIV TesƟng Yes: ☐ No: ☐ Results Made Available to the Employee: Yes:☐ No:☐ Date Made Available: Name of Medical Center: Name of TreaƟng Physician: Return Form to: City of Woodburn – Human Resources 270 Montgomery Street Woodburn, OR 97071 Phone: [PHONE REDACTED] Fax: [PHONE REDACTED]