Follow the steps listed below if a student, staff or faculty member has a: 

• percutaneous injury (needlestick or cut) from a contaminated instrument. 
• mucous membrane (splash to eye, nasal mucosa or mouth) exposure to body fluids.

Protocol

1. Immediately wash the exposed area with soap and water. Mucous membranes should be flushed with water or sterile saline. 
2. Inform the source individual of the incident without revealing the identity of the exposed individual. Keep the source patient in the clinic until they have been asked to consent for a blood draw at NUNM (Completion of FORM B below). 
3. Immediately report the exposure to the supervising faculty member or employee’s supervisor. 
4. The supervisor must fill out an online Incident Report (choose “Person Reporting a Bloodborne Exposure Report”). The exposed individual must fill out the Post-Exposure Follow-Up Form. Include as many details as you can regarding the incident including; the source patient’s information, the exposed individual’s information, how and where the exposure occurred, which PPE was used, the body part involved, the sharp involved, etc. 
5. The supervisor must also immediately call the Medical Director’s Office to notify of the exposure. If the call is not answered, please leave a voicemail. You can expect a call back within 24 hours. 
   • Dr. Taylor Boham – Assistant Medical Director 
   • Phone: 503-552-1619 
   • Email: Tboham@nunm.edu 
6. If the exposure occurs during NUNM Health Center Lab business hours, send the student/staff and source individual to the NUNM Lab to have their blood drawn immediately or as soon as possible. 
   • Download, print and provide the source individual with Form B and the exposed individual with Form C (Consents for Laboratory Testing). If the source patient or exposed individual declines to having their blood tested, document any contact/conversation and include it in the incident report. 
7. If the exposure occurs when the NUNM Lab is closed, or at an off-site facility and the patient is unable to get to the NUNM Lab, the location of lab testing will be dependent on the insurance of the individual. Please call the medical director’s office to help coordinate. 
8. The exposed individual may be requested to return to the lab at various intervals for follow up testing based on the results of the source patient and exposed individual.  
9. Lab results are sent to the Exposure Control Officer and kept on file. All HIPAA and, in the case of student exposure, FERPA rules regarding confidentiality of the source patient’s and NUNM student, staff or faculty member’s protected health information will be followed. 
10. The safety committee will record the incident (confidentially) in the “Log of Work-Related Injuries and Illnesses” and provide this information to Human Resources at the end of every calendar year. 
11. The Exposure Control Officer will conduct follow-up procedures and review the test results with the exposed student/staff/source individual. The exposed individual may begin post-exposure prophylactic treatment with the provider of their choice. The Exposure Control Officer will explain all options to the exposed individual. 

Refusal of Medical Evaluation, Exposure Testing and Post-Exposure Prophylaxis 

If the student, staff or faculty member refuses to be tested, they must download and fill out the Medical Evaluation Refusal Form (E) and make 2 copies. They should keep the original and give one copy to the Exposure Control Officer . 

Updated: 2025 February 24