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OCCUPATIONAL EXPOSURE INCIDENT REPORTFor use in this dental office/practice/facilityA SIGNIFICANT EXPOSURE OCCURS:1) Following percutaneous exposure (i.e., penetration of dental health care worker’s skin by a needle, a scalpelblade or other sharp object contaminated with a patient’s blood or other potentially infectious materials).2) Following contact between dental health care worker’s oral or nasal mucous membrane, cornea ornon-intact skin and patient blood, saliva or other potentially infectious materials (i.e., a splash ofpatient blood, saliva or other potentially infectious materials into the mouth, nose or eye of the dentalhealth care worker or direct contact of patient blood saliva or other potentially infectious material withan abrasion, cut or other opening in the skin of the dental health care worker).EMPLOYEE INFORMATIONExposed employee’s name:Phone:Position:FORM3Date of exposure:Date of HBV Vaccination:Date of Anti HBs test:FORUSE INOFFICEDate of last tetanus toxoid Vaccination:INCIDENT DESCRIPTION: (What occurred and where did it happen? Describe theexposure and whether this is a percutaneous, mucous membrane or corneal exposureas described above. What body part was affected?)Source patient antibody status (if known):SOURCE PATIENT INFORMATIONSource Patient HBsAg status: Positive NegativeHIV antibody status: Positive NegativeSource Patient HCV antibody status: Positive NegativeI, ____________________________ understand the significance of my exposure, as described above,I have been offered medical evaluation and treatment for the exposure but have decided, for personalreasons, not to have any such treatment.(Employer’s signature)(Employee’s signature)This document is CONFIDENTIAL and must be maintained by the employer for the length of employment plus 30 years.OSHA EXPOSURE CONTROL PLAN…a member benefit from the WDA 28
COMMUNICATION OF HAZARDS TO EMPLOYEES AND TRAININGIn this Dental Office/Practice/Facility:LABELS AND SIGNS(Name of assigned staff person) Will ensure that biohazard labels are affixed to containers of regulated waste, refrigerators andfreezers containing blood or other potentially infectious materials and other containers used tostore, transport or ship blood or other potentially infectious materials (e.g., extracted teeth, biopsymaterial).The universal biohazard symbol is used and this label must be fluorescent orange or orange red.Please note: Red bags or containers may be substituted for labels.However, regulated waste is handled in accordance with the rules andregulations of the agency (Wisconsin Department of Natural Resources)having jurisdiction over waste disposal regulations.EMPLOYER PAGEATTENTIONOSHA EXPOSURE CONTROL PLAN…a member benefit from the WDA 29
Page 4 and 5: TABLE OF CONTENTSHEPATITIS B VACCIN
Page 6 and 7: EXPOSURE CONTROL PLAN, PURPOSE AND
Page 8 and 9: EXPOSURE DETERMINATIONDEFINITIONOSH
Page 10 and 11: EXPOSURE DETERMINATION FORMFor use
Page 12 and 13: ENGINEERING AND WORK PRACTICE CONTR
Page 14 and 15: NEEDLESTICK SAFETY AND PREVENTION A
Page 20 and 21: PERSONAL PROTECTIVE EQUIPMENTThe pe
Page 22 and 23: PERSONAL PROTECTIVE EQUIPMENT CONTI
Page 24 and 25: HOUSEKEEPING CONTINUEDC. IN-HOUSE L
Page 26 and 27: HEPATITIS B VACCINATION AND ANTIBOD
Page 28 and 29: HEPATITIS B VACCINATION DECLINATION
Page 30 and 31: POST-EXPOSURE EVALUATION AND FOLLOW
Page 34 and 35: INFORMATION AND TRAININGIn this Den
Page 36 and 37: OSHA BLOODBORNE PATHOGENS STANDARD
Page 38 and 39: RECORD KEEPINGIn this Dental Office
Page 40 and 41: APPENDIXEMPLOYER REFERENCE PAGESOCC
Page 42 and 43: APPENDIXThe Hepatitis B vaccine doe
Page 44 and 45: APPENDIXEMPLOYER FREQUENTLY ASKED Q
Page 46 and 47: APPENDIXWEB SITES FOR REFERENCE DOC
Page 48 and 49: APPENDIXOSHA EXPOSURE CONTROL PLAN
Page 50 and 51: APPENDIXONLY FOR EMPLOYERS HIRING M
Page 52 and 53: OSHA EXPOSURE CONTROL PLAN…a memb

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