ࡱ> 02/  bjbj 499999MMMM Y MM0eeeee\\\$}f9\\\\\99ee\"9e9e\ePї$M~ 0M90\\\\\\\\\\M\\\\\\\\\\\\\ : REQUEST FOR SOURCE INDIVIDUAL EVALUATION Dear (Emergency Room Medical Director, Infection Control Practitioner); During a recent incident, one of our employees, staff or emergency care providers was involved in an event which may have resulted in an exposure to a Bloodborne Pathogen. I am asking that you perform and evaluation of the source individual who has produced this letter. Given the circumstances surrounding this event, please determine whether our employee is at risk for infection and/or requires medical follow-up. Attached is a Documentation and Identification of Source Individual which was initiated by the exposed worker. Please complete the source individual section and communicate the findings to the designated medical provider. The evaluation form has been developed to provide confidentiaity assurances for the patient and the exposed worker. Any communication regarding the findings is to be handled at the medical provider level. We understand that information relative to human immunodeficiency virus (HIV) and AIDS has specific protections under the law and cannot be disclosed or released without written consent of the patient. It is further understood that disclosure obligates persons who receive such information to hold it confidential. Thank you for your assistance in this very important matter. Sincerely, Dennis Lepore Health & Safety Control Officer )*su! "     Q S h$EhWCCJaJh$ECJaJh$Eh$ECJaJ*+tuv" $     F R S T c h`hgd$Eh^hgd$E21h:pWC/ =!"#$% j 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH J`J WCNormal dCJ_HaJmH sH tH DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List bob $EDefault 7$8$H$-B*CJOJQJ^J_HaJmH phsH tH PK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]    T  # AA@0(  B S  ? .<' Y6I$EWC@ `@UnknownG* Times New Roman5Symbol3. * Arial7.{ @CalibriACambria Math"qh&&  #r02HX  $P$E2!xxMazzocca, JanetMazzocca, JanetOh+'0|  8 D P\dltMazzocca, Janet Normal.dotmMazzocca, Janet2Microsoft Office Word@@ $@ $՜.+,0 hp|      Title  !"#$%&()*+,-.1Root Entry F0ݗ$3Data  1TableWordDocument4SummaryInformation(DocumentSummaryInformation8'CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q