Laboratory Infection Survey Form
Use this form to document laboratory infection incidents, affected area details, symptoms, response actions, and follow-up needs.
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
Laboratory area or room
*
Incident type
*
Suspected exposure
Confirmed infection
Contamination event
Needlestick/sharps injury
Spill/exposure
Other
Brief incident summary
*
Exposure and Infection Assessment
Suspected Source of Exposure
*
Please Select
Contaminated sample
Aerosol exposure
Surface contact
Needlestick or sharps incident
Animal contact
Unknown
Other
Affected Person Role
*
Lab Technician
Researcher
Student
Visitor
Other
Symptoms Observed
Fever
Cough
Rash
Headache
Nausea
Fatigue
Respiratory irritation
Eye irritation
No symptoms
Other
Severity Rating
*
1
2
3
4
5
Medical Evaluation Sought
*
Yes
No
Response and Follow-Up
Immediate Actions Taken
*
Rows
Action
Status
PPE donned
1
2
Area isolated
3
4
Spill/exposure contained
5
6
Decontamination started
7
8
Medical evaluation initiated
9
10
Containment or Cleanup Completed
*
Yes
No
In Progress
Reporting Status
*
Not Reported
Reported to Supervisor
Reported to Safety Officer
Reported to Infection Control
Follow-Up Required
Medical evaluation
Exposure monitoring
Incident review
Training refresher
Environmental cleaning verification
Other
Additional Comments
Submit
Should be Empty: