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EXPOSURE INCIDENT REPORT
EXPOSURE INCIDENT REPORT
EMPLOYEE’S NAME
EMPLOYEE’S JOB TITLE
DATE OF INCIDENT
TIME OF INCIDENT
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
LOCATION OF INCIDENT
TYPE OF EXPOSURE (CHECK ALL THAT APPLY)
Needlestick / Sharps Injury
Broken Skin
Blood or Body Fluid Splash
Other
Other
IMMEDIATE ACTIONS TAKEN
Area washed with soap and water
Mucous Membrane Exposure
Eyes/mucous membranes flushed
Supervisor notified=
PPE removed
DESCRIPTION OF INCIDENT
SOURCE INDIVIDUAL (IF KNOWN)
Name or Identifier
KNOWN BLOODBOURNE RISK
Yes
No
Unknow
AFTER YOU SUBMIT FORM, IF YOU HAVE NOT ALREADY, REACH OUT TO SUPERVISOR IMMEDIATLY FOR FURTHER INSTRUCTIONS
Submit
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