Immediate Action Checklist and Forms

  1. Student responsibilities
    1. Report the exposure incident to immediate supervisor.
    2. Seek immediate care (within two hours) and recommended follow-up care.
    3. Complete Form 1: Quick Form and Form 2: UND Incident Reporting Form within 24 hours.
    4. Route completed forms to UND, Dean's Office.
    5. If you refuse care, Form 4: Refusal of Care is required.

  2. Clinical Site Instructor/Supervisor/Preceptor responsibilities
    1. Facilitate immediate care and medical evaluation for student within two hours.
    2. Assist student with Form 1: Quick Form, including a medical provider signature to verify proper medical evaluation.
    3. Assist student with the online Form 2: UND Incident Reporting Form. Submit this form electronically within 24 hours.
    4. Collect and transport student's blood sample (if bloodborne pathogen exposure) to UND Student Health.

  3. UND Program Director responsibilities
    1. Investigate the exposure incident.
    2. Complete Form 3: UND Incident Investigation Part 1 and Part 2, and electronically submit this form to the Office of Safety.
    3. Verify completion of reports and appropriate routing.
    4. Verify blood sample arrival at UND student health (if bloodborne pathogen exposure).
    5. Retain record of incident.

  4. Chief of Staff, School of Medicine & Health Sciences responsibilities
    1. Notify appropriate program director of the exposure incident.
    2. Route copies of Forms 1 and 2 to appropriate program director.