Needle Stick Injury Report
Date of Incident
Time of Incident
Name of Person Reporting
Department/Unit
Role (e.g., Nurse, Doctor, etc.)
Location of Incident
Description of Incident
Type of Needle/Device
Procedure During Which Injury Occurred
Details of Exposure (if known patient, indicate if known infectious disease status)
Personal Protective Equipment Worn
First Aid Administered
Actions Taken After Incident
Suggestions for Preventing Similar Incidents