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00 t,, V -, P <br />DELTA BLOOD BANK <br />BIOSAFETY <br />Name Dept <br />Date, Time and Site of exposure <br />Job being Performed at exposure <br />Details of exposure <br />Describe Source of exposure (Donor No. etc) <br />Employee vaccinated? If yes, when? Full series?_ <br />Anti -HBs titer? <br />Source HBsAg status? Other <br />Evaluation of exposure risk <br />by <br />(signature) (date) <br />Postexposure management <br />HBIG? Date Dose <br />HBV vaccine - Series? Date begun <br />HBV vaccine booster? Date <br />*complete hepatitis B vaccine form <br />Counseling <br />i <br />by <br />(signature) <br />Fo11ow-up <br />(date) <br />by <br />r (signature) (date) <br />\, BIOSAFETY - HBVFORM - 0491 - POSTEXPO <br />