Bloodborne Exposure Incident Report Form printable pdf download

Bloodborne Exposure Incident Report Form

Institution _______

ID _______

Bloodborne Exposure Incident Report

-Questionnaire and Report-

Identification Number: ______________________________

Date of report: ______________________________

Date of exposure occurrence: ______________________________

Time of exposure __________am / pm

How many uninterrupted hours had you been working when this exposure occurred?: ________

Working Area:

A.__ Dental Operatory

B.__ Dental Laboratory

C.__ Sterilization Area

D.__ Emergency Clinic

E.__ Oral Surgery Clinic

F.__ Pediatric Clinic

G.__ Post-Graduate Clinics (specify________________)

H.__ Operating Room

I.__ Research Laboratory

J.__ Other (specify________________)

Professional Category:

A.__ Dental Faculty

Specialty ________________

B.__ Dental Assistant

C.__ Dental Hygienist

D.__ Dental Resident (year of residency 1,2,3,4,5)

Specialty ________________

E.__ Dental Student (academic year 1,2,3,4)

F.__ Dental Hygiene Student (academic year 1,2,3,4)

G.__ Dental Assistant Student (academic year 1,2)

H.__ Sterilization Technician

I.__ Laboratory Technician

J.__ Staff

K.__ Other (specify________________)

Have you had a previous exposure incident?: ___ Yes ___ No

9a.

If the answer to Question #9 is ‘Yes’, How many times have you been exposed?: ___

9b.

Was the previous exposure documented?: ___ Yes ___ No

EXPOSURE REPORT TEMPLATE

May 2000

Bloodborne Exposure Incident Report Form