Incident Report Post Exposure – Subtle Whisper Elite Care

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Incident Report - Post Exposure

Date of Report:

Month

Day

Year

Person Exposed:

Date of Exposure:

Month

Day

Year

Social Security Number

Time of Exposure:

Hours

Minutes

Where 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? YesNo

If "yes", provide the details:

Was there personal protective equipment or equipment malfunction? YesNo

If "yes", provide the details:

Were engineering controls being utilized when the incident occurred? YesNo

If "yes", provide the details:

Was the exposed person following safe work practices when the incident occurred? YesNo

If "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. YesNo

If first aid was administered to the exposed person, did the individual giving the first aid use personal protective equipment? YesNo

If "yes" indicate which type(s) were used:

GlovesMaskEyewearResuscitation Item(s)Other

Did an exposure incident occur? YesNo

If "yes", provide the details:

Was the exposed person previously vaccinated against the Hepatitis B Virus? YesNo

If "yes" give dates:

If "no", was Hepatitis B Series offered?

If "no", did the exposed person accept or decline the Hepatitis B Series? AcceptDecline

Is the source individual known? YesNo

If "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? YesNo

Provide details on post exposure management, counseling and follow-up:

Person completing form:

Position of person completing form:

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