Hofstra University Department of Physician Assistant Studies Post-Exposure Evaluation and Follow-Up Checklist Date of Report: __________________________ Name and Hofstra ID# of Student(s) involved in incident:____________________________ The following steps must be taken, and information transmitted, in the case of a student’s exposure to Bloodborne Pathogens: Activity Completion Date The Exposure Incident Investigation Form was completed If applicable, source individual’s blood tested and result given to exposed student. Consent was not obtained (__________________________________) Exposed Student’s Signature
If applicable, exposed student’s blood collected and tested. If refused, student must sign below. (__________________________________) Exposed Student’s Signature
If refused to see health care professional, then exposed student must sign below (_________________________________) Exposed Student’s Signature
Name of Hofstra Student Health Services Provider – Print and Signature: __________________________________________________________
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Date:_____________
