Notice of Specific Biohazard Exposure Incident

 

Date__________ Employee Name____________________________

 Route of Exposure:

__ Eye

__ Needle Stick

__ Non-intact skin

__ Other (Describe)_____________________________  

Describe the Incident________________________________________ __________________________________________________________ Action taken following the incident_____________________________ __________________________________________________________ __________________________________________________________   Was medical advice or treatment sought?  __yes  __  no  

If so, provide name and phone number of medical provider:__________________________________________________                                                    __________________________________________________________

   
Employee Signature Date
   
Supervisor Signature Date

 

Consent to draw and to test blood for HBV/HIV 

   
Employee Signature Date

 PLEASE NOTE:  This form must be filled out and provided to the Health & Safety Office and Personnel Department as soon as possible following the incident.