Bloodborne Pathogens Exposure Incident Report

Section 1 – To be completed by Exposed Employee, Direct Manager or Resource Manager,

Information about Exposed Employee:

First Name: Middle Initial:

Last Name: Division:

Office: Employee Number

Sex: M F Age:

Address:

Phone Number:

Employment Category: Length of Employment: Time in Occupation:

 Regular Full time  Regular Part time  Temporary  Non-employee

Section 2 – To be completed by Exposed Employee, Direct Manager or Resource Manager,

Information about Exposure Incident:

Date of Incident Time:

Specific Location of Incident:

Witness(es) to the Incident:

Employee's Usual Occupation:

Occupation at Time of Incident:

Direct Manager or Resource Manager

Phase of Employee's Workday at Time of Injury:

 Performing Work Duties  During Meals  During Rest Period
 Entering or Leaving Workplace  Other
General Type of Task Being Performed at Time of Incident:

Supervision at Time of Accident:

 Directly Supervised  Indirectly Supervised  Not Supervised  Supervision Not Feasible

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 Bloodborne Pathogens Exposure Incident Report

Description of Exposure Incident:

Location: Date: Time:

Details of Exposure Incident – Identify Type of Exposure, Frequency, Duration, Intensity and Exposure
Route

Name, Address, and Phone Number of Attending Physician (If Applicable):

Section 3 – To be completed by Exposed Employee, Direct Manager or Resource Manager,

Information about the Exposure Source (If known):

Name of Source Individual (If known):

Employer of Source Individual:

Contact Phone Number:

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