1. Home
  2. 4000s
  3. 4112.4, 4212.4E_Exhibit B Post-Exposure-Mgt-Release-Form

4112.4, 4212.4E_Exhibit B Post-Exposure-Mgt-Release-Form

Northfield Board of Education file code: 4112.4/4212.4

X Monitored

X Mandated

Exhibit B X Other Reasons

Northfield Public School District
2000 New Road
Northfield, NJ 08225



RE: Exposure to blood or other potentially infectious materials

Dear Parent/Guardian,

Pursuant to our discussion on the telephone, a staff person or student in our school has been exposed to your child’s blood or other body fluid. As a result, we have received a request, from the health-care provider listed below, for information about your child. The school would like to give this health-care provider your child’s name and your name, address and telephone number so that he/she can contact you directly to obtain the requested information. Since your consent is necessary for this type of disclosure, please complete and return this form to my attention at the school’s address if you authorize this release of information. Thank you.




Name: _________________________________________ D.O.B.: ___________________

(Student/Infant/Toddler: circle one)

Parent/Legal Guardian Information:

Name: _________________________________________

Address: _________________________________________


Telephone: _________________________________________

I hereby give consent to the Northfield Public School District to release the above information to:

______________________________________ (Name of Health-Care Provider making request).

As the parent/legal guardian of the above-named child, I authorize, by my signature below, the release of this information.

__________________________________________ _________________________

Signature of Parent/Legal Guardian Date

Was this article helpful to you? No Yes

How can we help?