Bloodborne Exposure Risk Assessment Form
Use this form to document a bloodborne exposure incident, assess exposure circumstances and severity, and determine immediate follow-up needs.
Exposure Details
Date and Time of Exposure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location / Unit / Department
*
Exposure Type / Source
*
Needlestick
Cut from contaminated sharp
Splash to eyes or mouth
Splash to broken skin
Contact with contaminated surface
Other
Brief Incident Description
Exposure Severity and Response
Source fluid type
*
Blood
Other potentially infectious material
Unsure
Visible blood present
*
Yes
No
Body area(s) exposed
*
Skin
Eyes
Mouth
Nose
Broken skin
Needle stick or cut
Other
Immediate first aid taken
*
Washed with soap and water
Flushed eyes with water or saline
Rinsed mouth or nose
Reported to supervisor
Sought medical evaluation
None
Other
Current symptoms or concerns
No current symptoms
Pain or tenderness
Redness or swelling
Bleeding
Burning or stinging
Blurred vision
Headache
Nausea or dizziness
Fever or chills
Anxiety or concern
Other
Assessment and Follow-Up
Risk Rating for This Exposure
*
1
2
3
4
5
Follow-Up Recommendation / Status
*
Please Select
Monitor only
Report to Occupational Health
Urgent clinical evaluation
Source testing needed
Other
Submit Assessment
Should be Empty: