Xavier University Bloodborne Pathogen Evaluation of an Exposure Incident

 

 Employee Name ___________________________ Date of Report ___________________

Date of Incident ___________________________ Time of Incident ___________________

1. Describe the duties being performed when the exposure occurred:

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2. Describe engineering controls and personal protective equipment in use at the time of exposure:

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3. Describe how the exposure occurred, needlestick, puncture of skin, splashing of blood or OPIM, etc.:

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4. Describe exactly what you were doing and how you were doing it when the exposure occurred:

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5. The following remedial action may minimize the likelihood of future exposure:

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Action taken by: ____________________________________ Date: _______________________

Employee?s Signature: _______________________________ Date: ______________________

Supervisor?s Signature: ______________________________ Date: ______________________

Note: Retain a copy and send the original to McGrath Health and Wellness Center