BLOODBORNE PATHOGEN EXPOSURE INCIDENT REPORT
EXPOSED INDIVIDUAL
Name: __________________________________________
Last
First
MI
Sex: ________________________
Date of Birth: ______________________
Month / Day / Year
SSN: _______________________
Job Position: _____________________
Phone: ______________________
Department: ______________________
Supervisor: __________________
Date of Incident: ________________________
Time of Incident: ________am/pm
Place of Incident: _______________________________________________________________________
Briefly Describe Incident: ________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Type of Exposure:
Needle stick/sharps accident
Contact with mucous membranes. Circle which: eyes, mouth, nose, other:____________
Contact with non-intact skin (circle all that apply)
broken, chapped, abraded, dermatitis, other skin defect: ___________________
Contact with intact skin
Bite
Other:_______________
Exposure To:
Blood
Internal body fluids
Circle which: cerebrospinal, synovial, pleural, amniotic, pericardial, peritoneal, other:____________
Vaginal secretions
Seminal fluid
Other:_______________
Did the fluid or secretions contain visible blood?
Yes
No
Exposure Control Plan, Exposed Individual - Exposure Incident Report, Page 1 of 3
Severity of Exposure/Wound Description:
If it was a needlestick injury:

Was it a hollow-bore needle?

Yes
No
What gauge needle was it? _____________________________
Was the skin broken?

Yes

No
Did the injury bleed freely?

Yes

No
Was the area?

Was antiseptic applied?

washed  flushed

Yes
No
Were gloves being used when the injury occurred?  Yes

No
How much fluid was involved?
How long was exposure?
How severe or deep was the injury?
Estimated time interval from patient until contact:
Source of Exposure:
Patient name, if known:
Infection Status of Source:

HIV or AIDS:
Positive

Negative
If unknown, risk is estimated to be:  High
 Unknown

Low
If positive, give any details regarding viral load, CD4 count or anti-retroviral susceptibility:
Hepatitis B:

Positive

Negative

If unknown, risk is estimated to be:  High
Unknown

Low
If positive, give any details regarding the status of HBsAg HBsAb, HBeAg, viral load or medication
susceptibility:
Hepatitis C:

Positive

Negative
If unknown, risk is estimated to be:  High

Unknown

Low
If positive, give any details regarding the status of Hep C Ab, viral load or medication susceptibility:
Other:
If the source individual has infection with another known bloodborne pathogen, give details:
Exposure Control Plan, Exposed Individual - Exposure Incident Report, Page 2 of 3
Susceptibility of the Exposed Person:
Has the exposed individual ever had exposure to or infection with?
Hepatitis B
 Yes
 No
Hepatitis C
 Yes
 No
HIV / AIDS
 Yes
 No
Other bloodborne pathogens?
 Yes
 No
If yes to any of the above, give details:
Hepatitis B vaccine history (number of doses and approximate dates):
Is anti-HBs status known?

Yes

No
If yes, when was the test and what were the results?
Other Relevant Details:
What other information do you feel is relevant to the evaluation and follow-up of this potential exposure incident?
Signature of the Exposed:
Signature of Medical Director or his designate:
Date: _____________________
Rev. 11/29/2001
ECP/VBCHD/Exposed-IncidentReport.doc
Exposure Control Plan, Exposed Individual - Exposure Incident Report, Page 3 of 3