Date/Time
of Injury: ___________________ Injured
Employee:__________________________ Employee
Title: __________________________
Sharps Injury: Did the device in use have engineered sharps injury protection?
yes
no
Type/brand
name of device involved in the exposure:__________________________ Was
the device used properly?
yes
no
Was
the protective mechanism activated?
yes
no
Did
the exposure occur before, during, or after activation?
before
during
after
When
did the exposure incident occur? (check one)
During use of sharp
Between steps of a multi-step procedure
After use and before disposal of sharp
While putting sharp into disposal container
Sharp left in inappropriate place
Overfilled sharps container
Disassembling
Other _________________________________________________
Location
in facility where exposure occurred: _________________________________________________ Procedure
being performed at the time of the incident: _________________________________________________ Body
part involved in the injury: _________________________________________________ Circumstances
of the exposure:
_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Engineering
controls/work practices/protective equipment/safety devices in use at
the time of the incident: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
Employee
sent to (Healthcare Professional)___________________
on (Date/Time)___________________
for evaluation and follow-up.
What
will be done to prevent this type of injury from recurring? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Date
Corrective Action Taken:___________________