Fillable Printable 57.205 Expbbf Blank

57.205 Expbbf Blank

Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2019

www.cdc.gov/nhsn

Exposure to Blood/Body Fl ui d s

Page 1 of 7 *required for saving

Facility ID#: _____________________Exposure Event #: __________________

*HCW ID#: _____________________

HCW Name, Last: _________________First: __________ _________Middle: ___________________

*Gender: □F □M□Other

*Date of Birth: _____ / _____ /______

*Work Location: ______________________________

*Occupation: ______________________If occupation is physician, indicate clinical specialty:___________________

Section I – General Exposure Information

1. *Did exposure occ ur i n this facility:

□Y □N

1a. If No, specify nam e of facility in which exposure occurred: _____________________________

2. *Date of exposure: _____ /_____ /___ ___

3. *Time of exposure: _______

□AM □PM

4. Number of hours on duty: _________

5. Is exposed person a temp/agency em pl oyee?

□Y □N

6. *Location where exposure occurred: ______________

7. *Type of exposure: (Check all that apply)

□7a. Percutaneous: Did exposure involv e a clean, unused needle or sh arp object?

□Y □N (If No, complete Q8, Q9, Sect i on II and Section V-XI)

□7b. Mucous membran e (Complete Q8, Q9, Sect ion III and Section V -XI)

□7c. Skin: Was skin intact? □Y □N □Unknown (If No, complete Q8, Q9, S ect ion III & Section V-XI)

□7d. Bite (Complete Q9 and Section IV-XI)

8. *Type of fluid/tiss ue i nvolved in exposur e: (C heck one)

□Blood/blood products□Body fluids: (Chec k one)

□Solutions (IV fluid, irrigation, etc.): (Check one)□Visibly bloody

□Visibly bloody□Not visibly bloody

□Not visibly bloody

□Tissue

If body fluid, indicate one body fluid type:

□Other (specify): ______ ________ ___ ____ ____ □Amniotic□Saliva

□Unknown□CSF□Sputum

□Pericardial□Tears

9. *Body site of exposure: (Check all that appl y)

□Peritoneal□Urine

□Hand/finger□Foot□Pleural□Feces/stool

□Eye□Mouth□Semen□Other (Specify):

□Arm□Nose□Synovial

_____________________

□Leg□Other (specify):□Vaginal fluid

____________________

Assurance of Confide nt iality:The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is

collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the

consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data

sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is

not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other

aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333,

ATTN: PRA (0920-0666).

CDC 57.205(Front), v6.6

Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2019

www.cdc.gov/nhsn

CDC 57.205 (Back), v6.6

Exposure to Blood/Body Fluids

Page 2 of 7

Section II – Percutaneous Injury

1. *Was the needle o r sharp object visibl y contaminated with blood prior to exposure? □Y □ N

2. Depth of the injury: (Check one)

□Superficial, surface scratch□Deep puncture or wound

□Moderate, penetrated sk in□Unknown

3. What needle or sharp object caused the inj ury (Check one)

□Device (select one)□Non-device sharp object (specify): ___________________□Unknown sharp object

Hollow-bore needle

□Arterial blood coll ect ion device□Biopsy needle□Bone marrow needle

□Hypodermic needle, attached to

syringe

□Hypodermic needle, attached to IV

tubing

□Unattached hypodermic needle

□IV catheter – central line□IV catheter – peripheral line□Huber needle

□Prefilled cartridge syrin ge □IV stylet□Spinal or epidural needle

□Hemodialysis needle□Dental aspirating syringe w/ needle□Vacuum tube holder/ne edle

□Winged-steel (Butterfly™ type)

needle

□Hollow-bore needle, ty pe unknown□Other hollow-bore needle

Suture needle

□Suture needle

Other solid sharps

□Bone cutter□Bur□Electrocautery device

□Elevator□Explorer□Extraction forceps

□File□Lancet□Microtome blade

□Pin□Razor□Retractor

□Rod (orthopedic) □Scaler/curette□Scalpel blade

□Scissors□Tenaculum□Trocar

□Wire

Glass

□Capillary tube□Blood collection tube□Medication ampule/v i al /bottle

□Pipette□Slide□Specimen/test/ vacuum tube

Plastic

□Capillary tube□Blood collection tube□Specimen/test/ vacuum tube

Non-sharp saf ety device

□Blood culture adapte r□Catheter securement device□IV deliverysystem

□Other known device (specify): _________________________________

4. Manufacturer and Model: _____________________________________

Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2019

www.cdc.gov/nhsn

CDC 57.205 (Back), v6.6

Exposure to Blood/Body Fluids

Page 3 of 7

5.Did the needle or other sharp object involved in the injury have a safety feature? □Y □N

5a. If Yes, indicate t ype of safety feature: (Check one) If No, skip to Q6.

□Bluntable needle, sharp□Needle/sharp eject or

□Hinged guard/shield □Mylar wrapping/pla sti c

□Retractable needl e/sharp□Other safety f eature (specify):____________________

□Sliding/gliding gua rd/ shield□Unknown safety mechanism

5b. If the device had a safety feature, when did the injury occur? (Check one)

□Before activation of the safety feature was

appropriate

□Safety feature failed, af ter activation

□During activat ion of the safety feature □Safety feature not acti vated

□Safety feature improp erly activated□Other (specify): ______ ________ ___ ____ _______ _

6. When did the injury occur? (Check one)

□Before use of the item□During or after disp osal

□During use of the it em□Unknown

□After use of the item before disposal

7. For what purpose or activity was the sharp d evice being used? (Che ck one)

Obtaining a blood s pecimen percutaneo usly

□Performing phlebotomy□Performing a fingerstick/heelstick

□Performing arterial puncture□Other blood-sampli ng procedure

(specify): ______________________ _____________

Giving a percutaneo us injection

□Giving an IM injection□Placing a skin test (e. g., tuberculin, allergy, etc.)

□Giving a SC injection

Performing a line related procedure

□Inserting or withdrawing a catheter□Injecting into a line or po rt

□Obtaining a blood sample from a central or

peripheral I.V. line or port

□Connecting an I.V. line

Performing surgery/autopsy/other invasive procedure

□Suturing □Palpating/exploring

□Incising□Specify procedure: ____________________________

Performing a dental procedure

□Hygiene (prophylaxis)□Oral surge ry

□Restoration (amalgam composite, crown)□Simple extraction

□Root canal□Surgical extraction

□Periodontal surgery

Handling a specimen

□Transferring B B F i nto a specimen container □Processing specimen

Other

□Other diagnosti c procedure (e.g., t horacentesis)□Unknown

□Other (specify): ______ ________ ___ ____ _______

Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2019

www.cdc.gov/nhsn

CDC 57.205 (Back), v6.6

Exposure to Blood/Body Fluids

Page 4 of 7

8. What was the activit y at the time of injury? (Check one)

□Cleaning room□Collecting/transpo rti ng waste

□Decontamination/ processing used equi pm ent□Disassembling device/equipment

□Handling equipment □Opening/breaking glass container (e.g. , ampule)

□Performing procedu re□Placing sharp in container

□Recapping□Transferring/passing/recei ving device

□Other (specify): ______ ________ ___ ____ _______ ____ ____ _

9. Who was holding the d evice at the time the i nj ury occurred? (Chec k one)

□Exposed person

□Co-worker/other pe rson

□No one, the sharp was an uncontrolled sharpin the environment

10. What happene d when the injury occurred? ( Check one)

□Patient moved and jarred device□Contact with overfil l ed/punctured shar ps c ontainer

□Device slipped□Improperly di sposed sharp

□Device rebounded□Other (specify): _______________________________

□Sharp was being reca pped□Unknown

□Collided with co-work er or other person

Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2019

www.cdc.gov/nhsn

CDC 57.205 (Back), v6.6

Exposure to Blood/Body Fluids

Page 5 of 7

Section III – Mucous Membrane and/or Skin Exposure

1. Estimate the amount of blood/bodyfluid exposure: (Chec k one)

□Small (<1 tsp or 5cc)□Large (> ¼ cup or 50cc)

□Moderate (>1 tsp and up to ¼ cup, or 6-50 cc)□Unknown

2. Activity/event when exposure occ urred: (Check one)

□Airway manipulation (e.g., suctioning ai rway ,

inducing sputum)

□Patient spit/cough ed/vomited

□Bleeding vessel□Phlebotomy

□Changing dressing/w ound care

□Surgical procedur e (e. g., all surgical procedures

including C-section)

□Cleaning/transporting contaminated equipment

□Tube placement/rem oval/manipulation (e.g., chest,

endotracheal, NG, rectal, urine catheter)

□Endoscopic procedures□Vaginal delivery

□IV or arterial line insert ion/removal/manipulation□Other (specify): ______ ________ ___ ____ _______ ___

□Irrigation procedu res□Unknown

□Manipulating bloo d t ube/bottle/speci m en

container

3. Barriers used by the worker at the time of exposure: (Check all that appl y)

□Face shield□Mask/respirator

□Gloves□Other (specify): ______ ________ ___ ____ _______ ___

□Goggles□No barriers

□Gown

Section IV – Bite

1. Wound description: (Check one)

□No spontaneous bleeding □Tissue avulsed

□Spontaneous bleeding□Unknown

2. Activity/event when exposure occ urred: (Check one)

□During dental procedure□Assault by patient

□Duringoral examination□Other (specify): ______ ________ ___ ____ _______ ___

□Providing oral hygiene □Unknown

□Providing non-oral care t o pat i ent

Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2019

www.cdc.gov/nhsn

CDC 57.205 (Back), v6.6

Exposure to Blood/Body Fluids

Page 6 of 7

Note: Section V-IX are required when following the protocols for Exposure Management.

Section V – Source Information

1. Was the source patient known? □Y □N

2. Was HIV status known at the time of exposure? □Y □N

3. Check the test re sult s f or the source patient (P=positive, N=negative, I=indeterm inate, U=unknown, R=refused, NT=not t est ed)

Hepatitis B P N I U R NT

HBsAg

HBeAg

Total anti-HBc

Anti-HBs

Hepatitis C

Anti-HCV EIA

Anti-HCV supplemental

PCR-HCV RNA

HIV

EIA, ELISA

Rapid HIV

Confirmatory test

Section VI – For HIV Infected Source

1. Stage of disease: (Check one)

□End-stage AIDS□Other symptomatic HIV, not AIDS

□AIDS□HIV infection, no symptoms

□Acute HIV illness□Unknown

2. Is the source patient taking anti-ret roviral drugs? □Y □N □U

2a. If yes, indicate drug(s):____________________________________________________________

3. Most recent CD4 count : ________mm

Date: ____ /______ (mo/ yr)

4. Viral load: _____ copies/ml _____ undetectableDate: ____ /______ (mo/yr)

Section VII – Initial Care Given to Healthcare Worker

1. HIV postexpos ure prophylaxis:

Offered? □Y □N □U Taken: □Y □N □U (If Yes, complete PEP form)

2. HBIG given? □Y □N □U

Date administered: ____ /____ /______ _

3. Hepatitis B v accin e given: □Y □N □U

Date 1

dose administered: ____ /____ /____ ___

4. Is the HCW pregnant? □Y □N □U

4a. If yes, which trimester? □1 □2 □3 □U

Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2019

www.cdc.gov/nhsn

CDC 57.205 (Back), v6.6

Exposure to Blood/Body Fluids

Page 7 of 7

Section VIII – Baseline Lab Testing

Was baseline testing performed on the H CW ? □Y □N □U If Yes, indicate results

TestDateResultTestDateResult

HIV EIA__ /__ /____P N I R ALT__ /__ /________ IU/L

HIV Confirmatory__ /__ /____P N I R Amylase__ /__ /________ IU/L

Hepatitis C anti-HCV-EIA__ /__ /____P N I R Blood glucose__ /__ /________ mmol/L

Hepatitis C anti-HCV-supp__ /__ /____P N I R Hematocrit__ /__ /________ %

Hepatitis C PRC HCV RNA__ /__ /____P N I Hemoglobin__ /__ /________ gm/L

Hepatitis B HBs Ag__ /__ /____P N I Platelets__ /__ /________ x10

Hepatitis B IgM anti-HBc__ /__ /____P N I Blood cells in Urine__ /__ /________ #/mm

Hepatitis B Total anti-HBc__ /__ /____P N I WBC__ /__ /________ x10

Hepatitis B Anti-HBs__ /__ /_________ mIU/mLCreatinine__ /__ /________ μmol/L

Result Codes: P=Positive, N=Negative, I=Indeterminate, R=Refused

Other: ____________ /__ /_______________

Section IX – Follow-up

1. Is it recommended that the HCW return f or f ol l ow-up of this exposur e? □Y □N

1a. If Yes, will follow-up be performed at this facility? □Y □N

Section X – Narrative

In the worker’s words, how did the injury occur?

Section XI – Prevention

In the worker’s words, what could have prevented the injury?

Custom Fields

LabelLabel

_____________________________/____/__________________________________/____/_____

______________________________________________________________________________

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