Exposure Incident Report

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?

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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