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Run: Employee Bloodborne Pathogen Exposure Incident Report

Use this Employee Bloodborne Pathogen Exposure Incident Report to document a workplace exposure, capture immediate response, and route the case for medical f...

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Report Overview

Date of report (required)

Time of report (required)

Reporter name (required)

Person completing the report. Collected for audit trail and follow-up.

Reporter role (required)

Type of exposure incident (required)

Brief incident summary (required)

Describe what happened, where it occurred, and the task being performed. Do not include unnecessary PII.

Exposed Employee

Employee name (required)

Employee ID

Optional if your organization uses an internal identifier.

Department or unit (required)

Job title

Work location (required)

Employee contact number

Optional contact detail for occupational health follow-up.

Exposure Details

Date of exposure (required)

Time of exposure (required)

Location of exposure (required)

Activity being performed (required)

For example: disposing of sharps, drawing blood, cleaning a spill, or handling specimens.

Exposure route (required)

Material involved (required)

PPE worn at the time

Exposure details (required)

Describe the body area exposed, approximate amount, and whether skin was intact.

Immediate Response

First aid provided (required)

Referred for medical evaluation? (required)

Time referred for medical evaluation

Supervisor notified? (required)

Time supervisor was notified

Source Material and Source Person

Is the source known? (required)

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? (required)

Medical evaluation completed? (required)

Hepatitis B vaccination status

Hepatitis B follow-up needed? (required)

Recommended follow-up actions

Follow-up notes

Document only the information needed for the audit trail and care coordination.

Get your results

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Email (required)

Your name (optional)

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