CSUB
BLOODBORNE PATHOGEN
POST EXPOSURE REPORT

Send To:	CSUB Personnel Department
		9001 Stockdale Hwy., Bakersfield, CA  93311

Please use this form for the physician's post exposure evaluation report to the employer.  
Complete the report and send it to CSUB Personnel within 15 days of completion of the 
post exposure evaluation. Document that the employee has been informed of the 
evaluation results and any medical conditions that require additional evaluation or 
treatment.  All other medical findings shall remain confidential and shall not be included 
in the post exposure report.  


NAME OF EMPLOYEE 

DATE OF INCIDENT 



INCIDENT DESCRIPTION (attach additional pages if necessary)


DID AN EXPOSURE INCIDENT OCCUR?  Yes No

An exposure incident is defined as a specific eye, mouth, mucous membrane, non-intact skin or 
parenteral contact with blood or other potentially infectious material that results from the 
performance of an employee's duties.

WAS ADMINISTRATION OF THE HBV VACINATION SERIES ADVISED?
	Yes No

HAS THE EMPLOYEE BEGUN THE HBV VACCINATION SERIES? 
	Yes No

    

  PHYSICIAN'S REPORT (attach additional pages if necessary)



PHYSICIAN'S SIGNATURE ____________________________	DATE __________