Sharps Disposal Safety Form
Report details on the safe handling and disposal of sharps. Please provide accurate information regarding the disposal process and any incidents.
Full Name of Person Submitting
*
First Name
Last Name
Department or Work Area
*
Date of Disposal
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Disposal Context
*
Routine disposal
Post-procedure cleanup
Emergency response
Other
Type of Sharps Disposed
*
Needles
Syringes
Lancets
Blades/Scalpels
Glass pipettes
Other
Estimated Quantity of Sharps Disposed
*
Current Containment Method
*
Please Select
Approved sharps container
Temporary hard-sided container
Improvised container (not recommended)
Other
Was there any exposure or incident during disposal?
*
No
Yes, needlestick or sharps injury
Yes, spill or contamination
Other
Action Taken After Incident (if any)
Additional Notes or Comments
Submit
Should be Empty: