Employee Bloodborne Pathogen Exposure Incident Report

Documents employee contact with blood or other potentially infectious material that may trigger medical evaluation, source testing, and Hepatitis B follow-up under OSHA 29 CFR 1910.1030.

Report Overview

• Date of report
• Time of report
• Reporter name
  Person completing the report. Collected for audit trail and follow-up.
• Reporter role
• Type of exposure incident
• Brief incident summary
  Describe what happened, where it occurred, and the task being performed. Do not include unnecessary PII.

Exposed Employee

• Employee name
• Employee ID
  Optional if your organization uses an internal identifier.
• Department or unit
• Job title
• Work location
• Employee contact number
  Optional contact detail for occupational health follow-up.

Exposure Details

• Date of exposure
• Time of exposure
• Location of exposure
• Activity being performed
  For example: disposing of sharps, drawing blood, cleaning a spill, or handling specimens.
• Exposure route
• Material involved
• PPE worn at the time
• Exposure details
  Describe the body area exposed, approximate amount, and whether skin was intact.

Immediate Response

• First aid provided
• Referred for medical evaluation?
• Time referred for medical evaluation
• Supervisor notified?
• Time supervisor was notified

Source Material and Source Person

• Is the source known?
• Source type
• Source identifier
  Use an internal identifier or masked reference when possible. Avoid collecting unnecessary PII.
• Source testing status
• Consent or authorization documented for source testing?

Medical Follow-Up and Hepatitis B

• Occupational health contacted?
• Medical evaluation completed?
• Hepatitis B vaccination status
• Hepatitis B follow-up needed?
• Recommended follow-up actions
• Follow-up notes
  Document only the information needed for the audit trail and care coordination.