Child’s Name:______________________ DOB: ____________________
Name of Daycare Center / Family Home: ________________
Date of Incident: ______________________________
Your child was involved in a biting incident that resulted in a break in the skin with bleeding. North Carolina law requires that all persons involved in a blood exposure be tested for Hepatitis B, Hepatitis C, and HIV. The following tests should be done:
- HBsAg- (also known as “Hepatitis B surface antigen”) This test indicates a Hepatitis B virus infection.
- Hepatitis C Antibody Screening.
Please present this letter to your physician so that the appropriate tests are done. Your physician will exchange tests results with the other child’s physician and notify you of the results. Please note testing should be completed within 5 business days of blood exposure so that results can be exchanged within a reasonable time period.
The Health Department requires confirmation of testing after a blood exposure. Please ask your physician to complete this form to show your child has had blood drawn to be tested for HIV/Hepatitis B/Hepatitis C. This note will be given to the director of your child’s center as confirmation of testing.
Doctor’s Name: _______________________________
Name of Practice: _____________________________
Phone Number: _______________________________
Date of test: __________________________________
What tests were performed: _____________________
Doctor’s signature: ____________________________
This form should be returned to Shawn Wilson, RN in Communicable Disease Control.
Phone 704-432-1975, FAX 704-353-1202