The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
Office of Emergency Medical Services
2 Boylston Street, 3rd Floor
Boston, MA 02116
(617) 753-7300
Fax: (617) 753-7320

MITT ROMNEY
GOVERNOR
KERRY HEALEY
LIEUTENANT GOVERNOR
RONALD PRESTON
SECRETARY
CHRISTINE C.  FERGUSON
COMMISSIONER	
MEMORANDUM

TO:		All Ambulance Services, First Responder Services, EMT Training Institutions
		Hospital Infection Control Departments
FROM:	Louise Goyette
RE:		Revised Unprotected Exposure Form
DATE:		May 26, 2004 (update of 12/27/00)

	Attached is the latest revision to the DPH Unprotected Exposure Form (UEF).  Please copy both sides and distribute this form as needed.  Additional copies are available from OEMS.

	Please note that advances in detection, prevention and/or treatment of exposures to HIV, hepatitis B virus and/or hepatitis C virus are occurring rapidly.  These advances now make it prudent for individuals who believe they may have suffered an unprotected exposure to blood or other body fluid to seek immediate medical evaluation.  Certain prophylactic treatments (i.e. treatment after exposure to HIV) should be started within hours of the unprotected exposure.

	Immediate medical evaluation of the exposed individual after what may be a significant exposure to blood or other potentially infectious material, takes precedence over completion of an UEF and/or waiting for the reporting mechanism to notify the exposed individual.

	Questions about exposures to infectious agents should be referred to your department’s Designated Infection Control Officer (DICO), your local physician, or your hospital infection control department.

MASSACHUSETTS
DEPARTMENT OF PUBLIC HEALTH
(DO NOT SEND THE ORIGINAL FORM OR A COPY TO THE DEPARTMENT OF PUBLIC HEALTH)

UNPROTECTED EXPOSURE FORM

(Please print or type)
Today’s Date
/      /      /      /      /	Incident Date
/      /      /      /      /	Receiving Facility
	
Transporting Ambulance Service
	Ambulance Trip Report #
	
Address
	Designated Infection Control Officer (DICO)
	
Telephone # for DICO
	It is recommended the prehospital emergency care agencies type or print in the name and telephone number of the current DICO before blank forms are provided to their personnel.	

Patient Information	Rescuer Information	
Name
	Name
	
Incident Location
	Address
	
Incident Type
                                 Medical                Trauma	City/State/Zip
	
Transportation
                                 Emergency           Routine	Day Phone 	Evening Phone	
Check box(es) which best indicate your exposure.
Explain in detail in the spaces provided below.	Profession 	Department/Employer	
Exposure Route:     Needlestick     Open cut       Bite       Puncture         Mouth      Eye       Other:____________________	
Exposure Type:      Blood              Sputum         Saliva     Other:__________________________________________________	
Precautions:           Mask         Eye Wear      Gown     Exam gloves             Gloves         Other:_______________________
                                                                                            (latex,nitrile,vinyl)        (work type)	
Cleaning                 Hand Washing               Washing Contaminated Skin           Other:_________________________________	

Describe the nature of the unprotected exposure in detail: (attach additional pages if needed)

	
Describe the steps taken by the rescuer to minimize the exposure:

	
You must provide the information on this form to the facility that received the patient from whom you received the exposure.  I understand that in the case of certain exposures (e.g. needlestick with a bloody needle) it is crucial for the exposed rescuer to seek immediate medical evaluation for treatment that might reduce the risk of infection.  Completion of the Unprotected Exposure Form may be done during or after the medical evaluation.

I further understand that I will be informed of an unprotected exposure, only if the patient is diagnosed as having a bloodborne infectious disease dangerous to the public health, as defined in 105 CMR 172.001 and if, in the view of medical personnel, my documented exposure is capable of transmitting that disease.

Rescuer’s Signature: ______________________________________ Date: _______________________

Form Received By: _______________________________________ Date: _______________________

DO NOT SEND THE ORIGINAL FORM OR A COPY TO THE DEPARTMENT OF PUBLIC HEALTH    Rev. 05/26/2004
(Side 1 of 2)							   (Instructions and Information on Reverse)
 (COPY BOTH SIDES!)

Massachusetts Department of Public Health
Unprotected Exposure Form

An Unprotected Exposure Form should be completed for any prehospital emergency care worker (e.g. an EMT, firefighter, police officer, or corrections officer) who believes he/she may have had an unprotected exposure to a patient’s blood or other contaminated body fluid(s) in the course of attending, assisting or transporting a person to a health care facility as part of his/her professional duties.  It is the responsibility of each care provider to complete and file a form with the receiving facility.

If you believe you may have had an unprotected exposure, you should seek immediate medical evaluation for possible prophylactic immunization and/or treatment, as indicated.  You must provide the information on this form to the facility that received the patient from whom you received the exposure.  Ambulance personnel or other emergency care providers having an unprotected exposure must complete a form on arrival and leave it at the health care facility with the patient.  Other individuals shall file their own forms with the receiving facility within 24 hours of the unprotected exposure.

The health care facility will review the information, which you provide and will determine if you have sustained an unprotected exposure as defined in DPH regulations.  If the patient to whom you were exposed is diagnosed as having a bloodborne infectious disease dangerous to the public health, and if you sustained an unprotected exposure which, in the opinion of the health care facility, is capable of transmitting such a disease, the facility shall provide oral notification within forty-eight (48) hours of the diagnosis and written notification within seventy-two (72) hours of the diagnosis.  This notice shall be given to the designated infection control officer for your agency who must be listed on the unprotected exposure form.  Upon notification, the designated infection control officer shall notify you.  The notice shall include the appropriate precautions and actions which you should take, the identity of the disease to which you were exposed, necessary precautions to prevent the transmission of the disease to others, and instructions to contact a physician for medical follow-up.  NOTE:  The health care facility’s determination that you have had an unprotected exposure does NOT necessarily indicate that you have contracted an infectious disease.  The report from the health care facility to the designated infection control officer to you is confidential and is governed by M.G. L. c.111, §111C and DPH regulations 105 CMR 170.000, 171.000 and 172.000.

N.B. – Due to the time it may take to diagnose a patient with an infectious disease, or the possibility that a patient may never be diagnosed, and the time it may take to notify you of the exposure, the Department recommends that anyone who believes they have suffered an unprotected exposure, such as a needlestick with a bloody needle, should see a physician immediately.  Certain prophylactic regimens should be started within hours of an unprotected exposure.

INSTRUCTIONS:

PLEASE PRINT CLEARLY

•	Complete all information on the form.
•	Check all boxes that apply:
	 the exposure route to you of a patient’s blood or bodily fluid(s).
	 the type of the patient’s bodily fluid(s) to which you were exposed.
	 body substance isolation precautions you used (even if they were breached).
	 post incident cleaning you performed.
	 if you checked any “Other” box(es), explain in the space(s) provided.
•	In the blank narrative sections explain fully the exposure and any treatment you have obtained.  Use additional blank sheets, if necessary, and staple them to the form.  The more accurately you explain the circumstances, the easier it will be for the facility personnel to evaluate your exposure.
•	EMT’s must also leave a copy of the ambulance trip record at the receiving facility.
•	Each EMT and other prehospital emergency medical health care providers who have sustained an unprotected exposure must file his/her own form.  The form(s) shall be submitted to the receiving health care facility upon patient arrival or within 24 hours.
•	Transportation or treatment of the patient(s) must not be delayed in order to complete the form(s).
•	Make a copy for your own records and/or for your designated infection control officer, in accordance with your employer’s policies and procedures.

DO NOT SEND THE ORIGINAL FORM OR A COPY TO THE DEPARTMENT OF PUBLIC HEALTH

(Side 2 of 2)										Rev. 05/26/2004