Bloodborne Exposure Incident Report Form Page 3
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8Institution _______
ID _______
15.
Describe the circumstances under which this exposure occurred. Be as specific as possible.
16.
Description of procedure in progress when exposure occurred:
A.__ Hygiene (e.g., prophylaxis, root planing, curettage)
B.__ Restorative (e.g., amalgam, composite, crown)
C.__ Root Canal
D.__ Periodontal Surgery
E.__ Oral Surgery
1.__Simple extraction
2.__Surgical extraction
3.__Fracture reduction
4.__Other (specify________________)
F.__ Other (specify________________)
17.
Where did the exposure occur?:
A.__ Inside patient’s mouth
B.__ Outside patient’s mouth
C.__ Unknown
18. When did the exposure occur?:
A.__ Before use of the item
B.__ During use of the item
C.__ After use but before disposal
D.__ During or after disposal
E.__ During cleaning
F.__ Unknown
EXPOSURE REPORT TEMPLATE
May 2000
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Parent category: Business