Transcription of NEEDLESTICK & SHARP INJURY REPORT
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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? ~ I01 Chapped ~ I02 Abraded ~ I03 Intact ~ B01 Yes ~ B02 No ~ B03 Unknown ~ I99 Other:_____ C. Was the Injured Person the Original User of the SHARP Item?
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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