Tuberculosis Exposure Incident Report

Date of Report

Month

Day

Year

Date of Exposure

Month

Day

Year

Name of Employee Exposed to TB

Name of Source Individual

Address Where Contact Took Place

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Details of Exposure Incident

Because of this exposure I realize that I may require testing and/or treatment due to the risk of developing Tuberculosis. I have been advised and encouraged to seek confidential assessment and follow-up by a Health Care Professional(s) and have been given the opportunity to do so, at no cost to myself, in accordance with OSHA, CDC and State Department of Health guidelines/regulations.

Because of this exposure I realize that I may require testing and/or treatment due to the risk of developing Tuberculosis. I have been advised and encouraged to seek confidential assessment and follow-up by a Health Care Professional(s) and have been given the opportunity to do so, at no cost to myself, in accordance with OSHA, CDC and State Department of Health guidelines/regulations. I accept assessment and follow-up as recommended: I do not accept assessment and follow-up as recommended:

Signature

Date

Supervisor/Agency Individual Responsible for TB Control Measures

Date

Physician

Date

SERVICING THE FOLLOWING COUNTIES AND CITIES :

Tuberculosis Exposure Incident Report

SERVICING THE FOLLOWING COUNTIES AND CITIES :

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