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Run: Bloodborne Pathogen Exposure Investigation

Use this Bloodborne Pathogen Exposure Investigation form to document needlestick, sharps, and body-fluid exposures, then capture follow-up, source testing, a...

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Exposure Event

Date of exposure (required)

When the exposure occurred.

Time of exposure (required)

Approximate time the exposure occurred.

Type of exposure (required)

Where did the exposure occur? (required)

Location or unit where the incident occurred.

Describe what happened (required)

Brief factual description of the incident, including what task was being performed and how the exposure occurred.

Was appropriate PPE worn? (required)

Immediate action taken (required)

Exposure Details

Route of exposure (required)

Device or item involved

For example: hollow-bore needle, scalpel, broken glass, contaminated dressing.

Was the device used on a patient or source? (required)

Fluid or material involved (required)

Exposure severity

Source Information

Is the source known? (required)

Source type

Source identifier

Use an internal identifier or initials if permitted by policy; do not enter full identifiers unless required by your process.

Source testing status

Are source test results available?

Exposed Person Follow-up

Was the exposed person notified of next steps? (required)

Was a medical evaluation completed? (required)

Evaluation date

Post-exposure prophylaxis offered or provided?

Work restrictions or follow-up instructions

Document any temporary restrictions or follow-up instructions from occupational health.

Corrective Actions and Review

Contributing factors

Corrective actions

Describe actions to prevent recurrence, such as training, device changes, or process updates.

Reported to (required)

Reviewer name

Name of the person completing the investigation review or approval.

Review date

Get your results

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Email (required)

Your name (optional)

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