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NEEDLESTICK & SHARP INJURY REPORT

EXPOSURE CONTROL 40B NEEDLESTICK - SHARP INJURY Form Page 1 of 1 NEEDLESTICK & SHARP INJURY REPORT NameofInjuredPerson: DateofInjury:TimeofInjury:JobAreaWhereIn cidentOccurred: : ~ A01 Doctor ~ A02 Nurse ~ H01 Hepatitis B ~ H02 Hepatitis C ~ H03 HIV ~ A03 Housekeeper ~ A04 Surgical Technologist ~ H04 Unknown ~ H99 Other:_____ ~ A99 Other: _____ I. Condition of Skin: B. Was the Source Patient Identifiable?

EXPOSURE CONTROL 40B Needlestick-Sharp Injury Form Page 1 of 1 NEEDLESTICK & SHARP INJURY REPORT Name of Injured Person: Date of Injury: Time of Injury: Job Area Where Incident Occurred:

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