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Run: Bloodborne Pathogen Exposure Report

Bloodborne Pathogen Exposure Report template for documenting needlestick, sharps, and body-fluid exposures, capturing the facts needed for immediate follow-u...

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Incident Details

Date of exposure (required)

Time of exposure (required)

Location of exposure (required)

Type of exposure (required)

Brief description of what happened (required)

Describe the event factually. Include the task being performed and how the exposure occurred.

Exposure Route and Body Area

Body area exposed (required)

Was a sharps device involved? (required)

Type of sharps device

Was PPE worn at the time?

Source Material and Source Patient

Is the source person or source material known? (required)

Source type

Source testing status

Source test result summary

Immediate Response and Medical Follow-Up

Immediate first aid performed (required)

Reported to supervisor or charge person? (required)

Was a medical evaluation completed? (required)

Post-exposure prophylaxis (PEP) status

Follow-up instructions provided

Summarize any return-to-work, lab testing, counseling, or follow-up instructions given.

Reporter and Review

Reporter name (required)

Reporter role (required)

Contact email

Optional. Provide only if needed for follow-up communication.

Additional notes

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Email (required)

Your name (optional)

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