Healthcare Worker Exposure Incident Report
Reporter Information
Name
Department/Unit
Date of Report
Job Title
Contact Number
Incident Details
Date of Incident
Time of Incident
Location of Incident
Type of Exposure
Needlestick/Sharps Injury
Mucosal Exposure
Non-intact Skin Exposure
Other
Describe the Incident
Immediate Action Taken
Was Personal Protective Equipment (PPE) Used?
Yes
No
If yes, specify PPE used
Source Information
Source Patient Name or ID (if known)
Diagnosis (if known)
Follow-Up
Notified Supervisor?
Yes
No
Supervisor Name
Recommended Next Steps