Hospital Needle Stick Injury Incident Report Form
Report and document needle stick injuries to support prompt investigation and follow-up in the hospital setting.
Name of Person Reporting the Incident
*
First Name
Last Name
Job Title/Role
*
Contact Email Address
*
example@example.com
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (e.g., department, room number)
*
Name of Exposed Staff Member (if different from reporter)
First Name
Last Name
Type of Needle/Device Involved
*
Please Select
Hollow-bore needle
Syringe needle
Suture needle
Lancet
Scalpel
Other
Describe How the Incident Occurred
*
Activity Being Performed at Time of Injury
*
Please Select
Administering injection
Drawing blood
Recapping needle
Disposing of needle/device
Cleaning up
Other
Was a Patient Involved?
*
Yes
No
If Yes, Patient's Initials (do not enter full name)
Type of Exposure
*
Blood
Body fluid (other than blood)
Unknown
Immediate Action Taken (select all that apply)
*
Washed area with soap and water
Reported to supervisor/manager
Sought medical evaluation
Other
Was a Supervisor or Manager Notified?
*
Yes
No
Additional Comments or Details (optional)
Submit Incident Report
Should be Empty: