Bloodborne Pathogens Exposure Reporting Form
Employee Name
Employee ID
Department
Date of Incident
Time of Incident
Location of Incident
Description of Exposure Incident
Route(s) of Exposure (e.g., needlestick, mucous membrane, cut, etc.)
Source of Blood/Body Fluid (if known)
Personal Protective Equipment (PPE) Used
First Aid Measures Taken
Supervisor/Manager Reported To
Witnesses (Name & Contact Info)
Employee Signature
Date
Supervisor Signature
Date