Yes      No

     [ ]      [ ]   HBV Vaccination Indicated?

     [ ]      [ ]   If indicated, HBV Vaccination Received?  _______________ (date)





On _____________________________ , ________________________________________________
             (date)                                    (name)


           

was evaluated by SIUC Health Services personnel for medical evaluation following an occupational exposure to human blood or other potentially infectious materials. He/She has been informed of the results of the post-exposure evaluation and has been informed of any medical conditions resulting form the exposure incident that require further evaluation or treatment.

  ____________________________     ______________________  _________________
                (signature)                    		(job title)            	        (date)