CONSENT & AUTHORIZATION FORM

I understand that in conjunction with my employment at EACC and in accordance with the
EACC Health and Safety program, the possibility may arise that may lead to the request of an
Infectious Disease (HIV/HBV) blood test. This would be due to a Blood borne incident that I
was either directly or indirectly involved with.

I, as the source individual in a Blood borne Incident, hereby give my consent and authorization
for laboratory blood specimen testing for the above mentioned Infectious Diseases.

This test must be performed within 72 hours of exposure and the results must be submitted to
EACC’s Human Resources department via a hard copy document from the performing
laboratory within 24 hours, if possible. In addition, I have been informed of all applicable laws
and HIPAA regulations concerning privacy and identity disclosure.

I have read and fully understand the foregoing and voluntarily consent to allow EACC or their
contracted medical/laboratory vendor to initiate the above such medical blood tests as deemed
appropriate. Therefore, my signature bellow represents my full consent and authorization to
these tests in accordance with EACC’s HSE policy and procedures.

Signature: Date:
Address:

Phone: