Needlestick Injury Incident Report
Use this report to document a needlestick or sharps-related injury, describe what happened, and note the immediate response and follow-up actions.
Incident Details
Incident Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident Time
*
Hour Minutes
AM
PM
AM/PM Option
Incident Location
*
Type of Incident
*
Needlestick
Sharps cut
Blood splash
Other
Incident Description / What Happened
*
Person Involved and Exposure Information
Role of Person Involved
*
Employee
Contractor
Student
Volunteer
Other
Department / Unit or Work Area
*
Body Part Exposed or Injured
*
Finger
Hand
Arm
Face
Eye
Other
Blood or Body Fluid Exposure Occurred?
*
Yes
No
Was the Source Device Known or Identifiable?
*
Yes
No
Unknown
Immediate Response and Follow-up
Immediate first aid or actions taken
*
Was the supervisor or manager notified?
*
Yes
No
Follow-up actions required
*
Occupational health review
Source testing
Medical evaluation
Incident investigation
Other
Submit incident report
Should be Empty: