Bloodborne Pathogen Exposure Incident Incident

NOTICE OF EMPLOYEES

Re: Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS) & Hepatitis C Employees are notified that a claim may be made for a condition, infection, disease or disability involving or related to the Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), or Hepatitis C within the provisions of the Arizona Workers’ Compensation Law, and the rules of The Industrial Commission of Arizona. Such a claim shall include the occurrence of a significant exposure at work, which generally means contact of an employee’s ruptured or broken skin

or mucous membrane with a person’s blood, semen, vaginal fluid, surgical fluid(s) or any other fluid(s) containing blood. AN EMPLOYEE MUST CONSULT A PHYSICIAN TO SUPPORT A CLAIM.

Claims cannot arise from sexual activity or illegal drug use. Certain classes of employees may more easily establish a claim related to HIV, AIS, or Hepatitis C if they meet the following requirements:

1. The employee’s regular course of employment involves handling or exposure to blood, semen, vaginal fluid, surgical fluid(s) or any other fluid(s) containing blood. Included in this category are health care providers, forensic laboratory workers, fire fighters, law enforcement officers, emergency medical technicians, paramedics and correctional officers.

2. NO LATER THAN TEN (10) CALENDAR DAYS after a possible significant exposure which arises out of and in the course of employment, the employee reports in writing to the employer the details of the exposure as provided by Commission rules. Reporting forms are available at the office of

this employer or from the Industrial Commission of Arizona, 800 W. Washington, Phoenix, Arizona 85007, (602) 542-4661 or 2675 E. Broadway, Tucson, Arizona 85716, (520) 628-5188. If an employee chooses not to complete the reporting form, that employee may be at risk of losing a prima facie claim.

3. NO LATER THAN TEN (10) CALENDAR DAYS after the possible significant exposure the employee has blood drawn, and NO LATER THAN THIRTY (30) CALENDAR DAYS the blood is tested for HIV OR HEPATITIS C by antibody testing and the test results are negative.

4. NO LATER THAN EIGHTEEN (18) MONTHS after the date of the possible significant exposure at work, the employee is retested and the results of the test are HIV positive or the employee has been diagnosed as positive for the presence of HIV, or NO LATER THAN SEVEN (7) MONTHS AFTER THE DATE OF THE POSSIBLE SIGNIFICANT EXPOSURE AT WORK, THE EMPLOYEE IS RETESTED AND THE RESULTS OF THE TEST ARE POSITIVE FOR THE PRESENCE OF Hepatitis C or the employee has been diagnosed as positive for the presence of Hepatitis C. KEEP POSTED IN CONSPICUOUS PLACE NEXT TO WORKERS’ COMPENSATION NOTICE TO EMPLOYEES THIS NOTICE APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE

APPENDIX F

REPORT OF SIGNIFICANT WORK EXPOSURE TO BODILY FLUIDS OR OTHER INFECTIOUS MATERIAL

(YOU MUST FILE THIS REPORT WITH YOUR EMPLOYER NO LATER THAN 10 DAYS AFTER YOUR EXPOSURE*)

Other Required Steps for Exposure to Blood or Bodily Fluids to Establish Prima Facie Claim for HIV, AIDS or Hepatitis C**

1. You must have blood drawn no later than ten (10) calendar days after exposure.
2. You must have blood tested for HIV or Hepatitis C by Antibody Testing no later than thirty (30) calendar days after exposure and test results must be negative.
3. You must be tested or diagnosed as HIV positive no later than eighteen (18) months after the exposure, or tested and diagnosed as positive for the presence of Hepatitis C within seven (7) months after the exposure.
4. You must file a worker’s compensation claim with the Industrial Commission of Arizona no later than one year from the date of diagnosis or positive blood test if you wish to receive benefits under the workers’ compensation system.

Other Required Steps to Establish Prima Facie Claim for MRSA, Spinal Meningitis or TB**

You must file a worker’s compensation claim with the Industrial Commission of Arizona no later than one year from the date of diagnosis if you wish to receive benefits under the workers’ compensation system.

*This form is not a claim form, but a report of exposure.

**Establishment of a prima facie claim is limited to certain classes of employees. For additional information regarding an industrially-related claim, condition, disease or disability involving or related to HIV, AIDS, Hepatitis C, MRSA, Spinal Meningitis or TB, please see the Notices required by law to be posted at your place of employment. You will also find this information at A.R.S. §§ 23-1043.02, 23-1043.03, 23-1043.04 and A.A.C. R20- 5-164.