Hospital Needle Stick Injury Report
General Information
Date of Incident
Time of Incident
Employee Name
Employee ID
Department/Unit
Job Title
Incident Details
Location of Incident
Witness(es)
Activity Being Performed
Type of Needle/Device Involved
Describe How Incident Occurred
Injury Information
Part of Body Injured
Was Personal Protective Equipment (PPE) Used?
Yes
No
First Aid Provided
Exposure Source Information
Known Source Patient?
Yes
No
Unknown
If Yes, Source Details
Additional Notes
Additional Information / Recommendations