Sexual Harassment

BISD Bloodborne Pathogens Submission Form
First Name:		Last Name:
Campus:		Employee ID:
Please answer the following questions below and click Submit.
1. I understand the purpose of this training was to minimize employee risk of exposure to blood or other infections body fluids through appropriate prevention control measures. I have reviewed the information and if I have additional questions, my contact person is my school nurse or Pat Sleeth, RN Coordinator of Health Services. I have reviewed the mandatory annual Bloodborne Pathogen training and understand the procedure.
YES
Belton ISD At-Risk Employees include: * Health service staff, athletic trainers, environmental specialists and principals * Teachers/Aides in PPCD and Life Skills * Coaches * Custodians * Bus drivers who provide transportation for the handicapped, other health impaired, or emotionally disturbed special education children If you are NOT an at-risk employee, the first box on question 2 has already been checked for you. If you ARE an at-risk employee, check other appropriate box Then submit
2. I understand that my position has been identified as a job classification that may have occupational exposure. I have the opportunity to receive the series of 3 Hepatitis B vaccine injections. I will contact my school nurse or Pat Sleeth about this information
N/A - I am not an at-risk employee as listed above OR - IF YOU ARE AN AT RISK EMPLOYEE, CHECK BELOW: I have received the Hepatitis B series of 3 injections and feel that I am adequately immunized. I DO NOT want the hepatitis B vaccine. I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B infection. I have been given the opportunity to be vaccinated at no charge to myself. However, I decline the Hepatitis B vaccine at this time. I DO WANT to receive the vaccine and will let the school set my appointment X I plan to receive the vaccine from my personal physician using my medical insurance for coverage

BISD Bloodborne Pathogens Submission Form