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Needle Stick Incident Report

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Needle Stick Incident Report

Please use the form below to report any incident, in which an employee is stuck by a needle or an unknow sharp object that could be a needle. For example: Complete the form if while an employee is removing trash, he/she is stuck by an unknown sharp object, which could possibly by a needle. Please call Human Resources if you have any questions at 540-568-3825.

Employee ID:
Name:
Social Security Number:
Department:
Position Title:
Object causing stick:

Description of incident:

Did employee seek medical treatment?
Yes No

Did the employee file a workers' compensation claim?
Yes No (Refer to the Workers' Compensation Form.)

Contact person for information:
Phone number for contact person:
Person submitting the form: