In case of exposure to bloodborne pathogen(s), complete this form and return to the Center for Environmental Health and Safety within 24 hours. A copy must be taken to the SIUC Health Service or other healthcare provider for post-exposure evaluation. If other persons were involved, attach additional copies of this form for each person involved.

Date of Report: Time of Report:

Name (Last, First, M.I.):

Sex: [ ] M [ ] F Social Security Number:

Address (Local): ______________________________________ Date of Birth _________ Work Phone:__________

______________________________________ Home Phone:_________

Status at time of exposure: Employee [ ] Student [ ] Faculty [ ] Other (Explain): [ ]

Job title: Duties related to exposure:

Has the exposed individual been immunized against hepatitis B virus? Yes [ ] No [ ]

Dates of immunization (1)_________(2)_________(3)_________

_____________________________________________________________________________________________

Place where exposure incident occurred: Date: Time:

Did incident arise out of and in the course of University employment? Yes [ ] No [ ]

Name of individual in charge of area where exposure occurred:

List any witnesses present:

Name: Address: Telephone:

Personal protective equipment in use at time of exposure:

Exposure to:

[ ] Blood [ ] Internal body fluids (circle one)

[ ] Body fluid with visible blood cerebrospinal, synovial, pleural,

[ ] Vaginal secretions amniotic, pericardial, peritoneal

[ ] Seminal fluid

Type of Exposure:

[ ] Needlestick/sharps accident

[ ] Contact with mucous membranes (eyes, mouth, nose)

[ ] Contact with skin (circle all that apply)

broken, chapped, abraded, dermatitis, prolonged contact, extensive contact

Severity of Exposure:

How much fluid?

How long was exposure?

How severe was the injury

Estimated time interval from exposure until medical evaluation:

Source of Exposure:

Source individual's name, if known:

Address: Phone:

Is a blood sample from the source available?

Is the source individual's HBV antigen/ antibody status known? Yes [ ] No [ ]

Is the source individual's HIV antibody status known? Yes [ ] No [ ]

Describe Activity Leading to Exposure:

[ ] Giving injection [ ] Cleaning blood spills

[ ] Recapping needles [ ] Handling waste products

[ ] Discarding needles [ ] Handling lab specimens

[ ] Handling IV lines [ ] Controlling bleeding

[ ] Handling disposal box [ ] Performing invasive procedure

[ ] Other:

Describe Situation Precisely:

Describe Immediate Interventions:

Was the area [ ] washed [ ] flushed?

Did injury bleed freely? [ ] yes [ ] no

Was antiseptic applied? [ ] yes [ ] no

Other:

Describe nature and scope of personal injury, if any: Was medical treatment obtained?

[ ] yes [ ] no

Name and address of hospital, physician or clinic where injured person was taken, if applicable:

Name of person completing form: Job title/occupation:

Signature: Phone number: Date:

Work:

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