Infectious Disease Exposure form-ALL but Police - City of Pittsburgh - pittsburghpa 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the INCIDENT/CCR NUMBER and ADDRESS OF INCIDENT in the designated fields. Ensure accuracy as this information is crucial for tracking the exposure.
3. Fill in your DEPARTMENT and UNIT/DIVISION, followed by your EMPLOYEE NAME, ADDRESS, OCCUPATION, D.O.B., SEX, and PHONE numbers (both Home and Work). This personal information helps identify you in relation to the incident.
4. Provide details about the SUBJECT'S NAME AND/OR SOURCE OF EXPOSURE, including AGE and SEX. If applicable, indicate the HOSPITAL where transport occurred and the DATE OF POTENTIAL EXPOSURE.
5. In the section for NAME OF POTENTIAL EXPOSURE (IF KNOWN), specify any known body fluids or suspected diseases involved. This is vital for health assessments.
6. Describe the incident thoroughly in the DESCRIPTION OF INCIDENT field. Include routes of entry and circumstances surrounding the potential exposure.
7. List INDIVIDUALS INVOLVED IN THE INCIDENT along with their NATURE OF INVOLVEMENT and PHONE numbers for follow-up if necessary.
8. Finally, sign and date where indicated for both EMPLOYEE SIGNATURE and SUPERVISOR SIGNATURE. Ensure that REPORT SUBMITTED BY is also completed with a date.

Start using our platform today to streamline your form completion process for free!