(a)  Any emergency service worker responding on behalf of a licensed ambulance/rescue service, or a fire department or a law enforcement agency who has sufficient reason to believe that, in the course of their professional duties, they have been exposed to bodily fluids or other substances that may result in the worker contracting a serious infection and/or illness shall complete a pre-healthcare facility exposure form. The worker shall file a copy of the form with the hospital or freestanding emergency-care facility receiving the transported patient believed to be the source of the infectious materials to which the worker believes he or she has been exposed. The worker shall file the form with the hospital or freestanding emergency-care facility immediately post exposure. The worker shall retain a copy of the completed form, except for that information protected by applicable confidentiality laws. The source patient’s diagnostic information shall not appear on the pre-healthcare facility exposure form.

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(b)  The director of the department of health, with the advice of the ambulance services advisory board, shall develop the pre-healthcare facility exposure form, and shall make copies available to all agencies employing emergency medical service workers, hospitals and freestanding emergency-care facilities.