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Provider Blood/Fluid Exposure

The Ryan White HIV/AIDS Treatment Extension Act of 2009 requires that a medical facility respond to the request of an Emergency Response Employee (ERE) and their Designated Infection Control Officer (DICO), of a potential exposure incident such as a needle-stick injury, other contact with body fluids, or suspicion of exposure to an airborne or aerosolized infectious disease.  This form will serve as notification. 

 The Emergency Department will follow the “Good Sam” exposure algorithm unless an EMS/Fire Agency/Provider have a different mechanism for follow-up, as stated in their agency Exposure Control Plan.  This is used for agencies/providers in the TJEMS area, both career and volunteer.  If the provider is an employee of UVA Medical Transport Network (Pegasus, Med V, NETS or SEMM) please refer to the employee algorithm, in addition to filling out these forms. 

Please complete this form in its entirety.  This not only provides the Universityof Virginia Health Systemwith your personal demographic information, it is also used to determine how exposures can be prevented in the future.  This documentation is suggested by OSHA’s Bloodborne Pathogen Standard. 

 Results of bloodwork (both source patient and ERE) will be ONLY be given to ERE or DICO by either the ED staff, Nursing Supervisor or Prehospital Coordinator. 

Exposure Form