Download BLOODBORNE EXPOSURE INCIDENT REPORT

BLOODBORNE EXPOSURE INCIDENT REPORT
Date of report: _______________ Date and Time of Exposure Incident:
Employee’s Name:
Employee’s Address:
Date of birth: ____________________ Date of Hire: _________________ Male: _____Female: _____
Job Classification/Department or Work Area:
Physician/ Healthcare provider to whom employee was referred:
If treatment was not on-site, where was it given? (Name and Address):
Was employee treated in an Emergency Room? _________
Was overnight hospitalization required? _______________
Report completed by: ____________________________ Title: _____________________Phone:
IF THIS IS NOT A SHARPS INJURY, COMPLETE THIS SECTION
Check the appropriate statement(s) below
______The incident resulted in exposure to the mucous membranes.
______The incident resulted in exposure to intact skin.
______The incident resulted in exposure to non-intact skin (Dermatitis, abrasions, or other evidence on non-intact
skin).
Complete all of the following, providing as much detail as possible.
Describe the task or procedure being performed when the exposure incident occurred:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
When during the procedure did the incident occur (Before, during or after)? _________________
Where (in the facility) did the incident occur?________________________________________________________
List the Personal Protective Equipment worn at the time of the incident:___________________________________
_____________________________________________________________________________________________
Evaluation of Exposure Incident: List what, if anything, can be changed to prevent a reoccurrence of this type of
exposure incident (Example: Wear safety glasses to protect eyes from splashes). Record changes in your written
plan:
IF THIS IS A SHARPS INJURY, COMPLETE THIS SECTION
Check the appropriate statement(s) below
______This is a sharps injury. The Sharps Injury Form must be completed in addition to this report.
______The exposure source is not a patient but has been identified. Details are attached (Example: dirty
instrument).
______The exposure source is a patient infected with a bloodborne disease (Information attached).
______The exposure source is a patient not infected with a bloodborne disease (Information attached).
______The exposure source is a patient; infectious status unknown. The patient consented to testing (Results
attached).
______The exposure source is a patient; infectious status unknown. The patient did not consent to testing.
______The exposure source is a patient: infectious status unknown. The patient was not asked to be tested.
______The exposure source is unknown.
______The incident involved exposure to blood.
______The incident involved exposure to OPIM (other potentially infectious materials) listed below: ____________
If any employee refuses Postexposure Evaluation and Follow-up, attach a signed copy of the Informed Refusal
(Declination) of Postexposure Evaluation. If this is a Sharps Injury, complete the information on the Sharps
Injury Form. Keep all information related to this incident in a confidential file. IMPORTANT! OSHA
REQUIRES THAT ALL EMPLOYEE MEDICAL RECORDS BE KEPT FOR 30 YEARS PLUS THE
TERM OF EMPLOYMENT. THESE RECORDS MUST BE CONFIDENTIAL.
Provided by HCP
Provided by HCP