Employee Bloodborne Pathogen Exposure Incident Report

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

Report Overview

• Date of Report
  When this report is being completed.
• Date of Exposure Incident
  When the exposure occurred.
• Time of Exposure Incident
  Approximate time the exposure occurred.
• Reporter Name
  Name of the person completing this report.
• Reporter Role
• Incident Location
  Where the exposure occurred.
• Exposure Type
  Select all that apply.
• Was immediate emergency care needed?
  Use this to route urgent cases for immediate medical attention.

Exposed Employee

• Employee Name
  Required for medical follow-up and internal reporting.
• Employee ID
  Optional internal identifier if used by your organization.
• Department
• Job Title
• Work Shift
• Supervisor Name

Exposure Details

• Material Exposed To
• Body Area Exposed
• Exposure Description
  Describe what happened, including the task being performed and how the exposure occurred.
• Were sharps involved?
• Sharps Type
• PPE Worn at Time of Exposure
• Exposure Severity

Source Material and Source Patient

• Is the source known?
• Is source testing or evaluation available?
• Source Patient Identifier
  Use a facility-approved identifier only. Avoid collecting unnecessary PII.
• Source Material Description
  Describe the source material if known, such as blood, body fluid, or OPIM.
• Is Hepatitis B status known?
• Source Hepatitis B Status

Immediate Response and Medical Follow-Up

• Immediate Actions Taken
• Was medical evaluation required?
• Evaluation Location
• Employee Hepatitis B Vaccine Status
• Is Hepatitis B follow-up needed?
• Post-Exposure Prophylaxis Recommended
• Follow-Up Instructions
  Document any instructions provided by occupational health or the treating provider.

Reporter and Review

• Reported to Supervisor?
• Supervisor Review Status
• Reviewer Comments
• Employee Acknowledgement
  Optional acknowledgement that the report is accurate to the best of the employee's knowledge.