Form
Form - Body Fluid Exposure Report and Post-Exposure Checklist
Document FSSMS-FRM-30Stage 1Revision 4Version 0.3.3
Topic pages open on your jurisdiction, and requirements tables show its line. You can change this on any page.
Confidential health record. Held by {{Infection Control Officer}}, never in the personnel file. Part A is completed by the member (or the officer with the member) within one hour of the exposure. Part B is completed by the designated infection control officer. One copy travels with the member to {{Post-Exposure Clinic}}. The clocks follow the Canadian Immunization Guide hepatitis B chapter (Public Health Agency of Canada, 2024) and the post-exposure protocol that applies in your jurisdiction (J25 Infection Control and Medical First Response); the general exposure history is kept separately on Form - Exposure Report.
| Field | Entry |
|---|---|
| Member ID and role | |
| Station and apparatus | |
| Incident number, date and time of exposure | |
| Location type (home, roadway, vehicle, station, other) | |
| Task at the time (airway, bleeding control, lift, search, needle use, cleanup, other) | |
| Route (percutaneous, mucous membrane, non-intact skin, respiratory, bite) | |
| Body part exposed | |
| Fluid (blood, visibly bloody fluid, other body fluid, unknown) | |
| Device involved; safety-engineered (yes/no); safety feature activated (yes/no) | |
| PPE worn at the time | |
| First aid given (wash, flush) and time | |
| Time reported to officer; officer role | |
| Time reported to designated officer | |
| Source patient available for testing (yes, no, unknown); receiving facility | |
| Witnesses (roles) | |
| Member’s hepatitis B immunity status, if known | |
| Member signature (ID) and date |
| Step | Clock | Time done | Initial |
|---|---|---|---|
| First aid confirmed (wash or flush); repeated if needed | At once | ||
| Report time checked against exposure time (target within one hour) | One hour | ||
| Significance assessed (route, fluid); clinician adviser consulted if unsure | At once | ||
| Member sent to {{Post-Exposure Clinic}} or emergency department; transport and cover arranged | At once | ||
| Source patient testing requested through the receiving hospital or EHS provider; who was asked, when | Two hours | ||
| Clinic given the member’s hepatitis B immunity status | At arrival | ||
| HIV post-exposure prophylaxis decision recorded (treating clinician; target within two hours; not generally after 72 hours) | Two hours | ||
| Hepatitis B immune globulin and vaccine decision for non-immune or unknown status (within seven days) | 24 hours | ||
| Baseline bloodwork drawn | Same day | ||
| Tuberculosis exposure: public health notified; baseline and follow-up testing arranged | 24 hours | ||
| Workers’ compensation employer report filed (by the deadline your jurisdiction sets: J08 Incident Reporting and Investigation) | Per clock | ||
| General exposure record filed (Form - Exposure Report) | Five working days | ||
| Follow-up schedule set: six weeks, three months, six months; member told who will contact them | Five working days | ||
| Support offered: peer support, employee assistance, paid time for appointments; family questions answered | 24 hours | ||
| Confidentiality confirmed: file held by designated officer; crew told only what the member agrees to | Throughout | ||
| Learning triage done (Tier 1 or Tier 2) per Incident Investigation and Learning Program; equipment or process finding to the Corrective Action Register | 24 hours | ||
| All follow-up complete; member confirms; file closed | Last follow-up |
Designated officer (role and ID), date opened, date closed: ________
| Field | Type | Required | Who completes |
|---|---|---|---|
| Member ID, role, station, apparatus | Text | Yes | Member |
| Incident number, date, time of exposure | Text, date, time | Yes | Member |
| Location type; task at the time; route; fluid | Pick lists | Yes | Member |
| Body part | Text | Yes | Member |
| Device; safety-engineered; feature activated | Text; yes/no; yes/no | If a device was involved | Member |
| PPE worn | Checkboxes | Yes | Member |
| First aid and time | Text, time | Yes | Member |
| Time reported to officer; officer role | Time, text | Yes | Member or officer |
| Time reported to designated officer | Time | Yes | Officer |
| Source patient available; receiving facility | Pick list, text | Yes | Officer |
| Witnesses (roles) | Text | No | Member |
| Hepatitis B immunity status | Pick list | If known | Member |
| Member signature and date | Signature, date | Yes | Member |
| Each Part B step: time done, initial | Time, initials | Yes for each applicable step | Designated officer |
| HIV PEP decision; HBIG decision | Pick list (started, not indicated, declined), time | Yes | Designated officer from clinic confirmation |
| Follow-up dates; compensation report date; date opened; date closed | Dates | Yes | Designated officer |
| Learning tier assigned | Pick list | Yes | Designated officer |
Retention: service plus 30 years, or longer where your jurisdiction’s retention rule for exposure and medical records requires it (J09 Records Retention); access limited to the designated officer, the occupational health provider and the member.
This chapter relies on the following legal requirements, which differ by province and territory. Check your jurisdiction’s section on each topic page before adopting it.
| Topic | What to check in your jurisdiction | Page |
|---|---|---|
| Incident Reporting and Investigation | The employer’s deadline to report a work injury or exposure with medical follow-up to the workers’ compensation board | J08 Incident Reporting and Investigation |
| Records Retention | Any retention period the law sets for exposure, health surveillance and medical records | J09 Records Retention |
| Infection Control and Medical First Response | The post-exposure protocol for blood and body fluid exposures, any law that allows source-patient testing, and occupational immunization expectations | J25 Infection Control and Medical First Response |
Public Health Agency of Canada. (2024). Canadian immunization guide (Part 3, Immunization of workers; Part 4, Hepatitis B vaccines). https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-7-hepatitis-b-vaccine.html