Needle Stick Injury Incident Report
Name of Injured Person
Department/Unit
Date of Incident
Time of Incident
Location of Incident
Job Title
Activity at Time of Injury
Type of Needle/Device Involved
Description of How Injury Occurred
Was Personal Protective Equipment (PPE) Used?
Yes
No
First Aid Administered
Reported To (Supervisor Name)
Actions Taken After Incident
Additional Comments