(1) A report of exposure must be filed with the health care facility by the designated officer on a form developed and approved by the department, entitled "Report of Exposure".

(2) The report form will require the following, at a minimum:

(a) name, address, and phone numbers of the emergency services provider who sustained an exposure;

(b) date and time of the exposure;

(c) a narrative description of the type of exposure that occurred, a detailed description of how the exposure took place, and a description of any precautions taken;

(d) the name and, if available, the date of birth of the patient;

(e) the name of the health care facility receiving the patient and the health care facility's infectious disease control officer;

(f) the name of the emergency services organization with which the health care provider was officially responding;

(g) the names and phone numbers of the designated officer and the alternate;

(h) the address of the designated officer to which the written notification required by 50-16-702 (2)(c), MCA, is to be sent; and

(i) the signature of the designated officer filing the report.

(3) A copy of the required form is available from the Department of Public Health and Human Services, Public Health and Safety Division, Emergency Medical Services and Trauma Systems Section, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951, telephone: (406)444-3895.

(4) An emergency service provider should, but is not required to, notify his designated officer within 72 hours after the exposure if he wishes a report of exposure to be filed.

(5) It is the department's interpretation that the information in 50-16-702 (2)(c), MCA requires a health care facility to provide to a designated officer in response to the filing with the facility of a report of exposure is limited to information related to the health care facility stay directly resulting from the incident that generated the exposure, and not to any subsequent emergency transport to that facility involving the same patient and the same emergency medical service. This interpretation is advisory only and not binding upon anyone.