Ala. Admin. Code r. 420-4-3-A – Appendix I

ATTACHMENT TO RULE 420-4-3-.04
APPENDIX 1

ALABAMA DEPARTMENT OF PUBLIC HEALTH
PHYSICIAN'S NOTIFICATION OF
HIV AND/OR HBV INFECTED HEALTH CARE WORKER

Information: The Infected Health Care Worker Management Act was signed into law on August 24, 1993. The purpose of the law is to prevent transmission of the Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV), or other disease designated by the State Board of Health from infected health care workers (IHCWs) to patients during the performance of exposure-prone invasive procedures. The law mandates "Any physician providing care to an infected health care worker shall notify the State Health Officer about the presence of the infection in the health care worker in a time and manner prescribed by the State Board of Health".

(SEE INSTRUCTIONS ON BACK FOR COMPLETING AND MAILING REPORT)

I.	PATIENT INFORMATION: Name:________________________________Sex:__Female__Male Address:_______________________________________________ Home Phone:_______________________Work Phone:__________ Date of Birth: ________ Social Security Number:__________
II.	EMPLOYMENT INFORMATION: Occupation:_____________________________________________ Name of Employer:_______________________________________ Address of Employer:____________________________________
III.	MEDICAL INFORMATION:
	A.	DIAGNOSIS:
	1)	HIV Positive: ___Yes ___No Date of Enzyme Immunoassay (EIA):_______________ Date of Western Blot:________________
	2)	Hepatitis B DNA Positive: ___Yes ___No
	#1 Test Date:_______________________
	#2 Test Date:_______________________
	B.	PRESENCE OF SYMPTOMS OR CONDITIONS: ___Dementia ___Dermatitis (Body Site:______________________________) ___Neuropathy ___Others (Please List):_______________________________ ____________________________________________________________
	C.	PAST HISTORY OF OCCUPATIONAL INJURY TO THE IHCW WHILE PERFORMING INVASIVE PROCEDURES: ___Yes ___No ___Don't Know SUBMITTING PHYSICIAN:_____________________________ Print or Type _________________________DATE:______ Signature

INSTRUCTIONS: This form is to be completed and returned within seven (7) days of the time a diagnosis is made or provision of care of such. Completed forms are to be sent to the designee of the State Health Officer by marking the envelope "Personal and Confidential" and sending it to:

Director, Bureau of Communicable Disease
Alabama Department of Public Health
201 Monroe Street, Suite 1400
P. O. Box 303017
Montgomery, Alabama 36l30-3017

Invasive Procedures as defined in the Infected Health Care Worker Management Act are:

(1) Those medical or surgical procedures characterized by the digital palpation of a needle tip in a body cavity or by the simultaneous presence of the health care worker's fingers and a needle or other sharp instrument or object in a poorly visualized or highly confined anatomic site.
(2) Invasive dental procedures shall include those that provide the opportunity for an intraoral percutaneous injury to the dental health care worker and could result in blood of the health care worker coming in contact with the blood or mucous membrane of the patient as adopted by the Board of Dental Examiners in rules developed pursuant to Section 11.

(3) These procedures shall not include physical examinations; blood pressure checks; eye examinations; phlebotomy; administering intramuscular, intradermal, or subcutaneous injections; needle aspirations; lumbar punctures; angiographic procedures; vaginal, oral, or rectal exams; endoscopic or bronchoscopic procedures; or placing and maintaining peripheral and central intravascular lines, nasogastric tubes, endotrachael tubes, rectal tubes, and urinary catheters.

ALABAMA PROCEDURES FOR ASSESSMENT AND PRACTICE MANAGEMENT OF HBV-, HCV-, AND HIV-, OR OTHER DISEASE SPECIFIED BY THE STATE BOARD OF HEALTH, INFECTED HEALTH CARE WORKERS (HCWs) FLOW CHART OF PROCEDURES

IHCW Reporting Source M.D.

30 Days 7 Days

SHO or
designee
30 days
Initiate Internal
Department Review

Invasive Procedures
Yes- Performed
SHO Convenes ERP
and
as required issues orders
temporarily limiting IHCWs
practice

30 days

Invasive Procedures
No- Perforemed
1. No ERP Convened
2. No limitation on Practice
3. IHCW to self-report (by law) future performance of
4. Information in confidential file
5. Notification of IHCW of results of investigation

ERP
1. Confidential hearing
2. Identity of IHCW protected
3. Review of IHCW's practice
4. Recommend limitations on performance of invasive procedures by IHCW
5. Make recommendations regarding need to notify patients who previously may have had an invasive procedure performed by IHCW
6. Report recommendations to SHO

Yes - Restrictions SHO Notifies 30 days		No - Restrictions SHO Notifies 30 days
1. IHCW 2. Institution(s) 3. Employer 4. Licensing Board (if applicable) Annual Internal Department Reviews		1. IHCW 2. Institution(s) 3. Employer 4. Licensing Board (if applicable) Annual Internal Department Reviews

IHCW Compliant with Restrictions	IHCW Non-Complaint with Restrictions	Invasive Yes-Procedures Performed	Invasive Yes-Procedures Performed
1. Investigation information sent to: a. IHCW b. Institutions(s) c. Employer d. Licensing board (if applicable 2. Annual Internal Department Reviews	1. Violations reported to appropriate licensing board (if applicable or to employer for for disciplinary action	SHO Convenes ERP	1. Investigation information sent to: a. IHCW b. Institutions(s) c. Employer d. Licensing board (if applicable 2. Annual Internal Department Reviews

Appeal Process
1. State Commitee of Public
Health within 30 days
2. Circuit Court within 30 days
3. Alabama Supreme Court