Sharps Exposure Incident Report Form
Report a sharps exposure incident by entering the incident details, exposure information, immediate actions taken, and reporter contact information.
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 / Department
*
Incident Type
*
Needlestick
Cut with contaminated sharp
Broken glass with exposure
Other specified sharps exposure
Exposure and Device Information
Sharp/Device Involved
*
Circumstances of Exposure
*
Blood or Body Fluid Exposure Occurred
Yes
No
Immediate Action Taken After Exposure
Washed area
Flushed mucous membrane
Reported to supervisor
Sought medical evaluation
Other
Reporter and Follow-up
Reporter Name
*
Follow-up Contact Number or Email
Submit Report
Should be Empty: