Bloodborne Pathogen Incident (Accident) Report Form printable pdf download

BLOODBORNE PATHOGEN INCIDENT (ACCIDENT) REPORT

Please read this form and the instructions thoroughly before filling out the form.

Immediate supervisor should complete this form promptly with employee input.

Please print clearly and forward to the Risk manager.

1._______________________________________________

2.____________________________________________

Employee

Immediate Supervisor

3._______________________________________________

4. ____________________________________________

Date of Incident/Accident

Time

5.__________________________________________________________________________________________________________

Incident/Accident Location and case number (if applicable)

6. Describe the Incident Fully (route of exposure, circumstances; describe type of controls in place at time of incident including

engineering controls and personal protective equipment worn; identify unsafe conditions and/or actions; relevant police reports).

____________________________________________________________________________________________________________

7. Describe employee's injury (part of the body/type of injury)

____________________________________________________________________________________________________________

8. Describe first aid/medical treatment (when and by whom)

____________________________________________________________________________________________________________

9. When was the incident reported ____________________________ To whom?_________________________________________

If not immediately reported, WHY? _______________________________________________________________________

10. List Names of Witnesses_____________________________________________________________________________________

___________________________________________________________________________________________________________

11. Is the source individual known? Yes____No____, if yes, please provide name/address so that a consent for blood testing can be

obtained.

Name: __________________________________ Address__________________________

DID THE SOURCE CONSENT TO BLOOD DRAW AND TESTING? Yes____ No ______

12. What corrective action was taken or is planned, to prevent similar accidents from occurring in the future?

____________________________________________________________________________________________________________

13. Referral to medical evaluator? Yes ______ No _______,

Date: _________________

If not explain:________________________________________________________________________________________________

NOTE: THE OREGON HEALTH DIVISION “SOURCE CONSENT” FORM WILL BE SENT BY THE EMPLOYEES TREATING

PHYSICIAN TO THE SOURCE OR HIS/HER MEDICAL PROVIDER TO ATTEMPT TO OBTAIN PERMISSION FOR SOURCE

HIV/HBV BLOOD TESTING. THE MEDICAL EVALUATOR HAS BEEN INFORMED AS TO OUR POLICY AND THE OSHA

RULES. ALL MEDICAL DATA IS CONFIDENTIAL.

NAME OF INVESTIGATOR:___________________________________________________

TITLE:_____________________________________________DATE:_________________

For additional comments please use additional paper

Bloodborne Pathogen Incident (Accident) Report Form