Exhibit 2, 242 FW 12
Instructions for the Evaluating Physician


Date: October 15, 2010

Series: Occupational Safety and Health

Part 242: Industrial Hygiene

Originating Office: Division of Safety and Health



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Attending Physician:


[Insert employee’s name]_     , a U.S. Fish and Wildlife Service employee, has experienced an actual or a potential exposure to human blood or other potentially infectious material.  The Occupational Safety and Health Administration’s Bloodborne Pathogen Standard, 29 CFR 1910.1030, requires us to have a medical evaluation of this exposure.


We are providing you with the following:


·        One copy of the Bloodborne Pathogen Standard (OSHA 29 CFR Part 1910.1030).

·        A summary of the employee’s duties as they relate to the exposure incident.

·        A summary of the route of exposure and the general circumstances about how the incident occurred.

·        Results of the source individual’s blood testing, if available.

·        Any medical information relevant to appropriate treatment, including vaccination status.


Medical Evaluation: We request that you:



1. Perform a physical examination of the employee commensurate with the exposure and requirements identified in the standard.


2. If the employee consents, collect and test his/her blood for Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) serological status.  Note:  If the employee consents to baseline blood collection, but does not give consent to HIV serological testing, you must preserve the sample for at least 90 days.  If within 90 days of the exposure incident our employee decides to have the baseline sample tested, you should test it as soon as feasible.


After completing the evaluation, please:



1. Provide the employee with the evaluation results.


2. Provide us with a written report stating that you have informed the exposed employee of the evaluation results and told him/her about any medical conditions resulting from exposure to blood or other potentially infectious materials that require further evaluation or treatment (Note: Any other findings or diagnoses should remain confidential and not be included in your written report).


3.  Include your written report with the other information required by the CA-16 Form Authorization for Examination and/or Treatment and return them to [INSERT facility/workplace Project Leader, Supervisor, or program coordinator name].


For additional questions, please contact: [Insert the supervisor’s information below].



Supervisor’s Name and Telephone Number


For information on the content of this exhibit, contact the Division of Safety and Health. For information about this Web site, contact Krista Bibb in the Division of Policy and Directives Management.  

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