I, ___________________________________, am employed by Forsyth Country Day School as a/an ________________________________________________________________________________.

As part of my job duties, I have been involved in an exposure incident.

The details of the incident are as follows (include type of body fluid, how it entered your body, the date the incident occurred, and the source, if known):

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Forsyth Country Day School has provided training for me regarding infection control and the risk of contracting disease as a part of my occupational duties. However, I, of my own free will, have decided not to accept post exposure testing and follow-up offered to me by the school.

I understand that signing this document releases Forsyth Country Day School of any responsibility regarding this exposure incident. I also realize that testing for this incident at a later date is not feasible because I have refused to have an initial blood sample drawn by a healthcare professional.

NAME_______________________________________________________________________

SOCIAL SECURITY NUMBER__________________________________________________

NAME OF WITNESS__________________________________________________________

SUPERVISOR’S NAME________________________________________________________

SIGNATURE/DATE___________________________________________________________