Rocky Vista University Medical Outreach Registration
Full Name as it appears on your Passport:
Date of Birth:
Country of issuance:
Cell Phone Number in the following format (xxx)xxx-xxxx:
Home Phone Number in the following format (xxx)xxx-xxxx:
To what country will you be traveling?
Date of departure:
Date of return:
Emergency Contact Information
Name of Emergency Contact:
Relationship to the Emergency Contact:
Phone Number for Emergency Contact in the following format (xxx)xxx-xxxx:
Email address for Emergency Contact:
Do you speak the language of the country to which you will be traveling?
What is your Shirt size?
Standard Protocol for a Needle Stick
If you are stuck by a needle or other sharp object or get blood or other potentially infectious materials in your eyes, nose, mouth or on broken skin, immediately flood the exposed area with water and clean any wound with soap and water or a skin disinfectant if available. Report the incident to your employer and seek immediate medical attention. Many employers have a procedural manual for steps to follow to guarantee that all risk-reducing steps are addressed. Notify the RVU Office of Clinical Affairs immediately.
Post-exposure Exam (can be done on site or after you return home)
During the first visit to a doctor following a needle stick, blood will be drawn to perform a baseline test, which checks for any virus or suspicious antibodies. Additional blood draws taken every 6 weeks, 12 weeks and 6 months after exposure check for activity of any viruses. Extended HIV follow-up (typically 12 months) is recommended for professionals infected with HCV after exposure to a source co-infected with both HIV and HCV. HIV testing should be performed on any exposed person who has an illness compatible with an acute retroviral syndrome, regardless of the interval since exposure.
Post-exposure prophylaxis (PEP)
According to the CDC, PEP is most effective if you take it within 2 hours of possible HIV exposure and should be taken for 3 days. At that time, you should consult your physician to see if you should take for a full 28 days. (Depends on risk level.)
Please refer to the attached tables from the CDC MMWR- September 5, 2005/Vol. 54/No.RR-9
You may be restricted of drug choice due to your location. The longer you wait to start PEP, the greater the risk of becoming HIV-positive. You may want to stop the rotation and make arrangements to come back to the US, especially if you are at High Risk for contracting infection.
The PEP for HBV is the Hepatitis B immune globulin and the HBV vaccine. You should already be vaccinated.
Post-exposure prophylaxis to prevent HIV infection
Fact sheet- 1 December 2014
Globally, there were an estimated 35 million people living with HIV, of whom 13 million were on antiretroviral treatment (ART) at the end of 2013.
People can be accidentally exposed to HIV though healthcare work or due to exposures outside healthcare setting, for example, through unprotected sex or sexual assault.
Antiretrovirals (ARVs) have been used to prevent infection in case of accidental exposures for many years. This intervention is called post exposure prophylaxis (PEP) and involves taking a 28-day course of ARVs.
PEP should be offered, and initiated as early as possible, for all individuals with an exposure that has the potential for HIV transmission, and ideally within 72 hours.
If started soon after exposure, PEP can reduce the risk of HIV infection by over 80%. Adherence to a full 28-day course of ARVs is critical to the effectiveness of the intervention.
Recent evidence shows PEP uptake has been insufficient: only 57% of the people who initiated PEP have completed the full course and rates were even lower at 40% for victims of sexual assault.
Why guidelines are needed
For many people that are accidentally exposed to HIV, PEP provides a single opportunity to prevent HIV after exposure. Such accidental exposures may be among health care workers who had needle stick injuries or among adults and children who survived sexual violence.
Access to timely PEP remains challenging in many settings in particular for non-health worker exposures (1l. Recent studies highlight the need to simplify approaches and improve the use of HIV PEP. Reported issues include, missed opportunities to provide PEP following sexual exposure in the United Kingdom !3l, lack of PEP protocols and limited compliance to guidance in China !4l, Nigeria !5) and UK !6), limited access to PEP by female sex workers in Kenya (7) and health workers in Uganda (B), and structural stigma that reduces PEP uptake among men who have sex with men in the United States of America !9)
Factsheet: post-exposure prophylaxis to prevent HIV infection
HIV topic: post-exposure prophylaxis
Use of antiretrovirals for treatment and prevention of HIV infection
Full Legal Name:
Country of Travel:
Dates of Travel:
Organization with which you will be traveling:
Release of Liability and Assumption of Risks for
THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISKS (the “Release”) is executed by the participant (the below signed) whose home address is stated below in favor of ROCKY VISTA UNIVERSITY, a Colorado for profit corporation (the “University”), whose address is 8401 South Chambers Road, Parker, Co. 80134 (CO) and 255 E. Center Street, Ivins, UT 84738 (UT).
I have read in full the information in this registration packet and understand the requiremnts to participate in this rotation/trip. I will comply with these requirements so I can be eligible to receive Clinical Education Rotation/Electve Credits for my time spent overseas.
Name of participant:
Name as it appears above:
Problems and Hazards that participants may experience include but are not limited to: