Transcription of NEEDLESTICK & SHARP INJURY REPORT
1 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? J. The INJURY Occurred: ~ C01 Yes ~ C02 No ~ J01 Before the use of the item (item broke/slipped while assembling, etc.)
2 D. The SHARP Item was: ~ J02 During use of the item (item slipped, patient jarred item, etc) ~ D01 Contaminated (known exposure to patient or contaminated equip. or items) ~ J03 While restraining patient ~ D02 Uncontaminated (no known exposure to patient or equipment) ~ J04 Between steps of a multi-step procedure ~ D03 Unknown ~ J05 While disassembling device or equipment (sorting, sterilizing, etc.) E. For What Purpose was the SHARP Item Originally Used? ~ J06 While recapping a used needle ~ E01 Unknown ~ E02 Injection ~ E03 Finger Stick ~ J07 Withdrawing a needle from rubber or other resistant material ~ E04 Suturing ~ E05 Cutting ~ E06 Drilling ~ J08 Device left on floor, stretcher, table, etc. ~ E07 Electrocautery ~ E08 To Draw Venous Blood Sample ~ J09 While putting item in disposal container ~ E09 To Connect to IV Line (piggyback/IV infusor/other) ~ J10 Item pierced side of disposal container ~ E10 Start IV or Heparin Lock (IV catheter or winged set type needle) ~ J11 Item protruding from disposal container ~ E99 Other:_____ ~ J99 Other: _____ F.
3 The INJURY Was: K. What Device Caused the INJURY ? ~ F01 Superficial (little or not bleeding) ~ F02 Moderate (skin punctured, some bleeding) L. Brand/Manufacturer of Product and Model Number: ~ F03 Severe (deep stick/cut, profuse bleeding) G. Was Any Fluid Injected? ~ G01 Yes ~ G02 NO ~ G03 Unknown M. Did the Item have a >Safety Design= (shielded, recessed, retractable, etc.)? If yes, give amount if known: _____ ~ M01 Yes ~ M02 No N. Describe the Circumstances Leading to the INJURY : O. Injured Person Seen By: P. Counseling, Post-Exposure Management, and Follow-Up: Manager=s Signature: Date.
