The department shall prescribe a form for use by the emergency services provider to notify the health care facility or alternate facility and the designated physician that the provider believes he or she has had a significant exposure to an infectious disease or condition. The form shall include identifying information for the emergency services provider, the provider agency, the designated physician, the patient, the patient’s attending physician, and the receiving health care facility or alternate facility, a description of the exposure, a description of the protective measures and equipment used by the provider to minimize exposure hazard, and such other information as is necessary to protect the public health and safety and to implement sections 71-507 to 71-513.