OSDH Form 207 "Communicable Disease Risk Exposure Report" - Oklahoma

What Is OSDH Form 207?

This is a legal form that was released by the Oklahoma State Department of Health - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2018;
  • The latest edition provided by the Oklahoma State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of OSDH Form 207 by clicking the link below or browse more documents and templates provided by the Oklahoma State Department of Health.

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Download OSDH Form 207 "Communicable Disease Risk Exposure Report" - Oklahoma

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INSTRUCTIONS
Oklahoma State Department of Health
Communicable Disease Risk Exposure Report
This report form was developed to initiate a system of notification for risk exposures occurring outside of a health
care facility to health care workers, emergency responders, and funeral workers as specified by the Oklahoma State
Department of Health OAC 310:555. This report and all information entered on it are to be held in strictest
confidence to conform with 63 O.S. Supp. 2001, Section 1-502.1 et. Seq.
Note: For questions regarding the handling of ODH Form 207, call 405/271-4636.
PART I: Exposed Worker Section
Questions 1-13 are to be completed by the exposed worker, immediately following the injury.
11:
Describe exposure in detail. Include information regarding type of exposure, body part affected,
type of body fluid involved, duration of exposure, etc.
13:
List the facility where the source patient was taken. This will be the facility that is responsible
for testing the source patient.
Questions 14-19 are to be completed by the Employer’s Designee, immediately following the injury.
Questions 20-22 are to be completed by a Licensed Health Care Professional (MD, DO, RN, PA).
Routing:
A. If the Licensed Health Care Professional determines that the exposure does not have the potential for
transmission of a communicable disease, the form should be returned to the Employer’s Designee.
B. If the exposure does have the potential for transmission of a communicable disease, the Yellow copy
should be mailed immediately to the OSDH HIV/STD Service (use gray, self-addressed, metered
envelope).
The Pink copy, a gray metered envelop and instruction page are to be delivered immediately to the
designated person (usually the Infection Control Practitioner) at the health care facility to which the source
patient was transported; to the attending physician, if the source patient was being cared for outside of a
health care facility; to the health care provider who last had responsibility for the deceased source patient;
or to the medical examiner.
PART II: Source Patient Health Care Provider Section
Questions 23-38 are to be completed by the Health Care Provider who is responsible for testing the source
patient.
32. Rapid HIV testing has become a valuable tool used to quickly determine the need for initiation and/or
continuation of PEP meds for the exposed person. When a rapid HIV test is performed on the source
patient, communication of these results should not be delayed. The results should be immediately
communicated to the physician/provider who is providing post/exposure counseling and follow up and
is listed on page 1. q. 17-19.
Please note that as other source results become available, these should be released to the Provider listed
on pate 1, q. 17-19.
Routing:
The Health Care Provider should complete Part II and mail the completed pink form to the OSDH
HIV/STD Service immediately using the gray, self-addressed, metered envelope.
OSDH Form 207
12/18
INSTRUCTIONS
Oklahoma State Department of Health
Communicable Disease Risk Exposure Report
This report form was developed to initiate a system of notification for risk exposures occurring outside of a health
care facility to health care workers, emergency responders, and funeral workers as specified by the Oklahoma State
Department of Health OAC 310:555. This report and all information entered on it are to be held in strictest
confidence to conform with 63 O.S. Supp. 2001, Section 1-502.1 et. Seq.
Note: For questions regarding the handling of ODH Form 207, call 405/271-4636.
PART I: Exposed Worker Section
Questions 1-13 are to be completed by the exposed worker, immediately following the injury.
11:
Describe exposure in detail. Include information regarding type of exposure, body part affected,
type of body fluid involved, duration of exposure, etc.
13:
List the facility where the source patient was taken. This will be the facility that is responsible
for testing the source patient.
Questions 14-19 are to be completed by the Employer’s Designee, immediately following the injury.
Questions 20-22 are to be completed by a Licensed Health Care Professional (MD, DO, RN, PA).
Routing:
A. If the Licensed Health Care Professional determines that the exposure does not have the potential for
transmission of a communicable disease, the form should be returned to the Employer’s Designee.
B. If the exposure does have the potential for transmission of a communicable disease, the Yellow copy
should be mailed immediately to the OSDH HIV/STD Service (use gray, self-addressed, metered
envelope).
The Pink copy, a gray metered envelop and instruction page are to be delivered immediately to the
designated person (usually the Infection Control Practitioner) at the health care facility to which the source
patient was transported; to the attending physician, if the source patient was being cared for outside of a
health care facility; to the health care provider who last had responsibility for the deceased source patient;
or to the medical examiner.
PART II: Source Patient Health Care Provider Section
Questions 23-38 are to be completed by the Health Care Provider who is responsible for testing the source
patient.
32. Rapid HIV testing has become a valuable tool used to quickly determine the need for initiation and/or
continuation of PEP meds for the exposed person. When a rapid HIV test is performed on the source
patient, communication of these results should not be delayed. The results should be immediately
communicated to the physician/provider who is providing post/exposure counseling and follow up and
is listed on page 1. q. 17-19.
Please note that as other source results become available, these should be released to the Provider listed
on pate 1, q. 17-19.
Routing:
The Health Care Provider should complete Part II and mail the completed pink form to the OSDH
HIV/STD Service immediately using the gray, self-addressed, metered envelope.
OSDH Form 207
12/18
Communicable Disease Risk Exposure Report
The filing of this report initiates a system of notification for risk exposures occurring outside of a health care facility
to health care workers, emergency responders and funeral workers as specified by the Oklahoma State Department
of Health OAC 310:555. This report and all information entered on it are to be held in strictest confidence in
conformance with 63 O.S. Supp. 2001, Section 1-502.1 et. Seq.
Part 1: Exposed Worker Section (Please Print)
1. Employee Name:
2. Birth date:
/
/
(Last)
(First)
(MI)
(Mo/Day/Yr.)
3. Home Telephone (
)
4. Professional/Job Title:
5. Employer/Company Name:
6. Work Address/Telephone:
(Street)
(City)
(Zip)
Telephone
7. Number of hepatitis B vaccinations previously received: ☐None; ☐ 1:
☐2: ☐ 3
8. Date of Exposure: (Mo/Day/Yr.) ___/___/___ 9. Time of Exposure:
AM or PM (Circle One)
10. Supervisor’s Name/Telephone:
(
)
Telephone
11. Description of Exposure:
12. Source Patient Name:
(Last)
(First)
(M.I.)
13. Location of Source Patient (include name of facility, address and phone number):
To be completed by Employers’ Designee:
I have reviewed the circumstances and management of this incident and verify that the appropriate follow-up (according to our
agency Exposure Control Plan) is being attempted in order to identify or prevent the transmission of communicable diseases to
which the employee may be at risk as a result of this exposure.
14.
15.
16.
/
/
Name & Title (Print)
Signature
Mo.
Day
Yr.
Post-exposure counseling and follow-up will be provided to this employee by:
17.
18.
19.
Provider’s Name
Provider’s Telephone Number
Provider’s Fax Number
To Be Completed by a Licensed Health Care Professional (MD, DO, RN, PA)
In my professional judgment, this ☐ was ☐ was not a mucosal, percutaneous or respiratory exposure that has the potential
for transmission of a communicable disease, such as hepatitis B, hepatitis C, HIV, TB or meningococcus.
20.
21.
22.
/
/
Name & Title (Print)
Signature
Mo.
Day
Yr.
For consultation regarding exposures and PEP meds: PEP Hotline: 1-888-448-4911
Note: If this exposure does not warrant medical follow-up, please return the form to the Employer’s Designee and indicate to that individual why
no follow-up is required.
If this is an exposure that warrants medical follow-up, the employer shall handle the report accordingly.
th
A. Yellow copy to be mailed Immediately to the OSDH HIV/STD Service (use gray, self-addressed, metered envelope) at 1000 NE 10
St., OKC, OK 73110.
B. Pink copy, a gray metered envelop and instruction page to be delivered Immediately to the designated person (usually the Infection Control Practitioner) at the
location of the source patient.
OSDH Form 207
12/18
Part II: Source Patient Health Care Provider Section (Please Print)
23. Date and time 207 Form received:
/
/
Time:
AM or PM (Circle one)
(Mo/Day/Yr.)
24. Person completing Part II:
(Last)
(First)
(Title)
25. Institution (name):
Business Phone:
Source Patient Information
☐ Male
☐ Female
26. Birth Date: (Mo./Day/Yr.)
27. Sex:
28. Primary Diagnosis:
29. Was the patient found to have any potentially communicable disease(s), such as hepatitis B, hepatitis C, HIV,
TB, meningococcal disease, or others?
☐ Yes
☐ No
30. If yes, specify:
31. Does the source patient have any clinical evidence of AIDS or symptoms of HIV infection or acute retroviral syndrome?
Source Patient Test Results
☐ Invalid
☐ Not Done
32. Rapid HIV test:
Test Date:
☐Positive
☐Negative
(Mo/Day/Yr.)
Note: IMMEDIATELY report Rapid HIV results by phone or fax to the Provider listed on page 1, q. 17-19. As other test
results become available, these are also to be released to the Provider listed on page 1, q. 17-19.
33. HBsAg:
☐ Not done
Test Date:
☐Positive;
☐Negative
(Mo/Day/Yr.)
☐ Not done
34. anti-HCV:
Test Date:
☐Positive;
☐Negative
(Mo/Day/Yr.)
☐Positive; ☐ Negative
☐Not done
35. HIV :
Test Date:
(Mo/Day/Yr.)
☐Indeterminate
36. Other:
Name of Test:
Test Result:
Test Date:
(Mo/Day/Yr.)
Note: Source results may be released to the source patient; the exposed person’s physician/provider or ODH per OAC
310:555.
37. Date results release to Provider:
38. Date mailed to OSDH:
(Mo/Day/Yr.)
(Mo/Day/Yr.)
When Part II is completed, mail immediately to the OSDH HIV/STD Service using the gray self-addressed, metered
envelope.
Part III: OSDH Section (Please Print)
Date Report Received:
Person Completing Part III.
(Mo/Day/Yr.)
(Last)
(First)
OSDH Division:
Follow-Up Action:
OSDH Form 207
12/18
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