MMH Team Member Bloodborne Pathogens Exposure

• Exposure #:

• Case #:

• Site

• Conducted on

  Date

• Prepared by:

• Sign:

  Sign

• Exposure Follow up Completed:

  Date

Exposure Details:

• Date of Incident:

  Date

• Department where incident occured:

• Individual:

  Employee

  Contractor

  Volunteer

  Student

• Source:

  Known Source

  Unknown Source

• Nature:

  Sharps

  Splash

  Near Miss

• Presented for treatment:

  Occupational Health

  Emergency Services

• Date Reported:

  Date

• Reported To:

• Type of Device/Equipment:

• Brand Name of Device/Equipment:

• Location of Incident:
  Address

Describe What Happened

• Enter Discription:

• Was any equipment involved?

  Yes

  No

  N/A

• Pertinent Photos:

  Yes

  No

  N/A

What action was taken immediately after the incident?

• Enter description

Can any improvements be made as a result of this occurrence?

• Details