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Forms Manager
Exposure Incident Report
Routes and Circumstances of Exposure Incident
Date completed
Victim's Name
Best Contact Phone
Business Phone
Date of Birth
Employee Job Title or Student
Victim's Vaccination Status
Date of Exposure
Time of Exposure (please indicate a.m. or p.m.)
Location of Incident (building, street, etc. - be specific)
Nature of Incident, be specific (i.e. accident while cleaning, sports, trauma, medical emergency)
Describe what task(s) you were performing when the exposure occurred, be specific
Were you wearing personal protective equipment (PPE)?
Yes
No
If yes, list:
Did the PPE fail?
Yes
No
If yes, explain how:
What body fluids were you exposed to, be specific (i.e. blood or other potentially infectius material)?
What parts of your body became exposed, be specific?
Estimate the size of the area of your body that was exposed.
For how long?
Did a foreign object penetrate your body? (i.e. needle, nail or other sharps etc.)
Yes
No
If yes, what was the object?
Where did it penetrate your body?
Was any fluid injected into your body?
Yes
No
If yes, what fluid?
How much?
Did you receive medical attention?
Yes
No
If yes, where?
When?
By whom?
Identification of source individual(s)
Name(s)
Did you treat the patient directly?
Yes
No
If yes, what treatment did you provide, be specific?
Other pertinent information:
Name of supervisor or person preparing this report & date
Full name of the employee or student & date
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