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State Form Number 51467 (11-11)
This form is to be completed by the exposed Emergency Medical Services Provider.
Name of Section
|Information Needed to Complete Section|
Information Regarding Emergency Medical Services Provider Exposed to Blood or Body Fluids
|Basic demographic information: It is vital to provide a contact telephone number for both the exposed provider and the provider's employer. Please note that you are entitled to choose all the racial categories that apply to you. Ensure that racial and ethnicity questions are completed.|
|Basic information specific to exposure: Run number (if applicable), date, time, location, name and date of birth of Source person(s)
Fill in the circle for each type of body fluid(s) that the provider encountered in the exposure.
Fill in the circle(s) that describes how the exposure occurred. The exposure must be of a type that has been demonstrated epidemiologically to transmit a dangerous communicable disease.
Submitting the Completed Form
|The completed State Form 51467 (R/11-11) must be sent to the medical director of the emergency medical services provider's employer, the medical director of the emergency department, and the Indiana State Department of Health (ISDH). Please provide the additional requested information. Because the law addresses the time frames in which notification must occur to the medical director of the Emergency Medical Services Provider's employer and the medical director of the emergency department of the medical facility (if applicable), it is crucial that the date and time that the form is submitted be included in this section of the form. The ISDH requests that the form be submitted by fax to 317/234-2812. You may also send the form by mail to the ISDH at the following address:
Indiana State Department of Health, 2 North Meridian Street , 5K, Indianapolis , IN 46204.
Exposure Follow-up Notification
|The exposed Emergency Medical Services Provider must name a physician who will receive the test results from the medical facility and relate those results to the exposed emergency medical services provider.|
Signature and Date
|The exposed Emergency Medical Services Provider must sign and date the form, using the date that the form is completed.|
Page last updated: August 1, 2016
Page last reviewed: August 1, 2016