Incident Report - Post Exposure Date of Report: MonthDayYearPerson Exposed: Date of Exposure: MonthDayYearSocial Security NumberTime of Exposure: HoursMinutesAMPMWhere did the exposure incident take place? What was the route(s) of exposure?Provide details of the incident including what activities the exposed person was performing when it occurred. Was exposed person wearing/using personal protective equipment when the incident occurred? YesNoIf "yes", provide the details: Was there personal protective equipment or equipment malfunction? YesNoIf "yes", provide the details: Were engineering controls being utilized when the incident occurred? YesNoIf "yes", provide the details: Was the exposed person following safe work practices when the incident occurred? YesNoIf "yes", provide the details: Were blood and/or other body fluids involved? If “yes”, provide details on which one(s) were involved, the amount of each and the origin of each. YesNoIf first aid was administered to the exposed person, did the individual giving the first aid use personal protective equipment? YesNoIf "yes" indicate which type(s) were used: GlovesMaskEyewearResuscitation Item(s)OtherDid an exposure incident occur? YesNoIf "yes", provide the details: Was the exposed person previously vaccinated against the Hepatitis B Virus? YesNoIf "yes" give dates: If "no", was Hepatitis B Series offered? If "no", did the exposed person accept or decline the Hepatitis B Series? AcceptDeclineIs the source individual known? YesNoIf "yes" provide name of source individual (unless prohibited by state law)What actions can be taken to reduce or eliminate the chances of similar exposure incidents from occurring again? Had the exposed person received training on infection control? YesNoProvide details on post exposure management, counseling and follow-up:Person completing form: Position of person completing form: Send Message SERVICING THE FOLLOWING COUNTIES AND CITIES : Faulkner County | Grant County | Lonoke County | Perry County | Pulaski County | Saline County Beebe | Benton | Bryant | Cabot | Conway | Jacksonville | Little Rock | Lonoke | North Little Rock | Searcy Site Navigation LOCATION 222 Alfa Rd. North Little Rock AR 72117 Ph : (501) 500 - 6888 Fax: (501) 500 - 6881 follow us on social Facebook Instagram