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This incident report is to be used to report incidents of exposure to human blood or other body fluids while performing duties not regularly a part of the employees job. For example: nurses, lab technicians handling blood and housekeepers do not need to use this form.

Employee ID:
Employee Name:
Department:
Job Title:
Person Reporting the Incident:
Contact Person for More Information:
Date of Incident:

Description of Incident:

Was the employee stuck by a needle?
Yes No If yes, please complete the Needle Stick Reporting Form

Did you wear Personal Protective Equipment (gloves, apron, etc) when attending to the employee?
Yes No

Did you dispose of sharps (razor blades, needles, knives) in the designated bio-hazard container?
Yes No

Did blood spill on surface, furniture or equipment?
Yes No

If yes, did trained personnel cleanse with bleach 1:10 ratio mixed fresh?
Yes No

Were bandages or other materials containing blood placed in bio-hazard bags?
Yes No

Did you or the person assisting come in contact with the employee's blood?
Yes No

If yes, did the person exposed to blood wash hands thoroughly and flush exposed area with water?
Yes No

Has the employee exposed to blood or other human body fluids been offered the HBV vaccination?
Yes No