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Run: Employee Bloodborne Pathogen Exposure Incident Report

Use this incident report to document a blood or other potentially infectious material exposure, capture immediate response, and route the employee into medic...

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Report Overview

Date of Report (required)

When this report is being completed.

Date of Exposure Incident (required)

When the exposure occurred.

Time of Exposure Incident (required)

Approximate time the exposure occurred.

Reporter Name (required)

Name of the person completing this report.

Reporter Role (required)

Incident Location (required)

Where the exposure occurred.

Exposure Type (required)

Select all that apply.

Was immediate emergency care needed? (required)

Use this to route urgent cases for immediate medical attention.

Exposed Employee

Employee Name (required)

Required for medical follow-up and internal reporting.

Employee ID

Optional internal identifier if used by your organization.

Department (required)

Job Title

Work Shift

Supervisor Name

Exposure Details

Material Exposed To (required)

Body Area Exposed (required)

Exposure Description (required)

Describe what happened, including the task being performed and how the exposure occurred.

Were sharps involved? (required)

Sharps Type

PPE Worn at Time of Exposure

Exposure Severity (required)

Source Material and Source Patient

Is the source known? (required)

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 (required)

Was medical evaluation required? (required)

Evaluation Location

Employee Hepatitis B Vaccine Status

Is Hepatitis B follow-up needed? (required)

Post-Exposure Prophylaxis Recommended

Follow-Up Instructions

Document any instructions provided by occupational health or the treating provider.

Reporter and Review

Reported to Supervisor? (required)

Supervisor Review Status

Reviewer Comments

Employee Acknowledgement

Optional acknowledgement that the report is accurate to the best of the employee's knowledge.

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