Safety at Xavier

Evaluation of an Exposure Incident

Xavier University Bloodborne Pathogen Evaluation of an Exposure Incident

Employee Name ___________________________ Date of Report ___________________

Date of Incident ___________________________ Time of Incident ___________________

1. Describe the duties being performed when the exposure occurred:

__________________________________________________________________________________

2. Describe engineering controls and personal protective equipment in use at the time of exposure:

__________________________________________________________________________________

3. Describe how the exposure occurred, needlestick, puncture of skin, splashing of blood or OPIM, etc.:

__________________________________________________________________________________

4. Describe exactly what you were doing and how you were doing it when the exposure occurred:

__________________________________________________________________________________

5. The following remedial action may minimize the likelihood of future exposure:

__________________________________________________________________________________

Action taken by: ____________________________________ Date: _______________________

Employee's Signature: _______________________________ Date: ______________________

Supervisor's Signature: ______________________________ Date: ______________________

Note: Retain a copy and send the original to McGrath Health and Wellness Center