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CAMPUS ENVIRONMENTAL SAFETY & HEALTH |
BLOODBORNE PATHOGEN INCIDENT FORM
Employee Instructions: Please fill in the requested information.
NAME: ______________________________________________________________________________________
DATE OF INCIDENT: _________________________________ DATE OF FORM: ______________________
BUILDING LOCATION: _______________________________ ROOM OR LAB: ______________________
PHONE EXTENSION: _______________________________
EMPLOYEE EXPLANATION OF HOW THE INCIDENT HAPPENED:
(How the incident happened) ___________________________________________________________________
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(Reactive measures taken) ______________________________________________________________
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REPORTED TO: __________________________________________
TEL. #: _________________________
(Name)
DATE:
__________________________________________
March 2003