Needlestick Injury Incident Report Form
Report a needlestick injury incident by providing detailed and accurate information below. All fields are required.
Name of person completing this report
*
Reporter contact information
*
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 / department
*
Person involved in the incident
*
Was the person exposed to blood or other body fluids?
*
Yes
No
Unknown
Brief description of how the incident occurred
*
Was the supervisor or manager notified?
*
Yes
No
Supervisor/Manager Name
*
Submit Report
Should be Empty: