Laboratory Needle Stick Incident Report
Date of Incident
Time of Incident
Full Name
Position/Title
Department / Laboratory
Location of Incident
Activity Being Performed
Description of Incident
Type of Needle/Device Involved
Were gloves worn?
Yes
No
Other PPE Used
Was the needle used on a patient/animal or with hazardous material?
Yes
No
First Aid Actions Taken
Supervisor Notified
Witness(es)
Recommendations/Preventive Actions