Bloodborne Pathogen Incident (Accident) Report Form (Page 2 of 2) in pdf

INSTRUCTIONS ON COMPLETING THE INCIDENT (ACCIDENT) REPORT FORM

The information request on this incident form is required by the OSHA regulations. The form is to allow the investigator

a method of summarizing the findings so a written record of the County’s investigation can be retained as part of our

overall OSHA compliance plan.

An exposure incident as defined by this plan and the OSHA rules means: a specific eye, mouth, other mucous membrane,

non-intact skin, or skin piercing contact (parenteral contact) with blood or other potentially infectious materials that

results from the performance of an employee’s duties.

TEM #

INSTRUCTION

1. Employee

Enter the name of the employee reporting an exposure incident.

2. Supervisor

Enter the name of the employee's immediate supervisor.

3. Incident Date

Enter the date of the specific exposure incident.

4. Time

Time of day the specific exposure incident occurred.

5. Location # case number

Physical location of the employee at the time of the exposure incident.

6. Description of the Incident

A detailed description of the incident is required by the OSHA rule. The investigator needs to

include the following information:

> The route of exposure, circumstance which resulted in the exposure.

> Controls that were in place at time of the incident including: engineering controls and

personal protection equipment worn.

> Identify any unsafe conditions or action by the employee.

7. Employee's injury

Describe what part of the body the employee had contact with blood or OPIM and injuries that

may have been suffered.

8. First aid given

Describe any first aid that was provided to the exposed employee.

9. Date of Incident Reported

When did the employee inform management of the incident and to whom

10. Witnesses

List the names of other County employees who may have witnessed the incident.

11. Source

Is there a known source and will the person consent to blood testing?

12. Corrective actions

What are the recommended procedural or program changes to reduce or prevent reoccurrence of

this exposure incident.

13. Referral

Has medical referral been done, if not, explain

> Bottom of the Page List the name of the investigator(s), job title(s) and date of report.

Bloodborne Pathogen Incident (Accident) Report Form Page 2