**[Sample]{.underline} Blood and Body Fluid Exposure Report Form**

<table>
<colgroup>
<col style="width: 13%" />
<col style="width: 4%" />
<col style="width: 9%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 8%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 12%" />
</colgroup>
<tbody>
<tr class="odd">
<td><h2 id="facility-name">Facility name:</h2></td>
<td colspan="5"><h2 id="section"></h2></td>
<td colspan="3"><h2 id="section-1"></h2></td>
<td colspan="5"><h2 id="section-2"></h2></td>
<td colspan="3"><h2 id="section-3"></h2></td>
<td colspan="2"><h2 id="section-4"></h2></td>
</tr>
<tr class="even">
<td colspan="3"><h1 id="section-5"></h1></td>
<td colspan="3"><h1 id="section-6"></h1></td>
<td colspan="3"><h1 id="section-7"></h1></td>
<td colspan="2"><h1 id="section-8"></h1></td>
<td colspan="6"><h1 id="section-9"></h1></td>
<td><h1 id="section-10"></h1></td>
<td><h1 id="section-11"></h1></td>
</tr>
<tr class="odd">
<td colspan="3"><h1 id="name-of-exposed-worker-last">Name of exposed
worker: Last </h1></td>
<td colspan="3"><h1 id="section-12"></h1></td>
<td colspan="3"><h1 id="section-13"></h1></td>
<td><h1 id="first">First :</h1></td>
<td colspan="7"><h1 id="section-14"> </h1></td>
<td><h1 id="id">ID #:</h1></td>
<td><h1 id="section-15"></h1></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="7"><strong>Date of exposure: _________
/________/________</strong></td>
<td colspan="10"><h5 id="time-of-exposure-_____________">Time of
exposure: ______:_______</h5></td>
<td colspan="2"><strong>AM PM</strong> (Circle)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"><h1 id="job-titleoccupation">Job
title/occupation:</h1></td>
<td colspan="4"><h1 id="section-16"></h1></td>
<td colspan="3"><h1 id="section-17"></h1></td>
<td colspan="6"><h1 id="departmentwork-unit">Department/work unit:
</h1></td>
<td colspan="4"><h1 id="section-18"></h1></td>
</tr>
<tr class="even">
<td colspan="2"><h1 id="section-19"></h1></td>
<td colspan="4"><h1 id="section-20"></h1></td>
<td colspan="3"><h1 id="section-21"></h1></td>
<td colspan="4"><h1 id="section-22"></h1></td>
<td colspan="4"><h1 id="section-23"></h1></td>
<td colspan="2"><h1 id="section-24"></h1></td>
</tr>
<tr class="odd">
<td colspan="5"><h1 id="location-where-exposure-occurred">Location where
exposure occurred:</h1></td>
<td colspan="3"><h1 id="section-25"></h1></td>
<td colspan="4"><h1 id="section-26"></h1></td>
<td colspan="4"><h1 id="section-27"></h1></td>
<td colspan="3"><h1 id="section-28"></h1></td>
</tr>
<tr class="even">
<td colspan="4"><h1 id="section-29"></h1></td>
<td colspan="2"><h1 id="section-30"></h1></td>
<td colspan="3"><h1 id="section-31"></h1></td>
<td colspan="4"><h1 id="section-32"></h1></td>
<td colspan="4"><h1 id="section-33"></h1></td>
<td colspan="2"><h1 id="section-34"></h1></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Name of person completing form:</strong></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

**Section I. Type of Exposure** *(Check all that apply.)*

  -- -- ------------------------------------------------------------------- --
        **Percutaneous (Needle or sharp object that was in contact with     
        blood or body fluids)**                                             

        *(Complete Sections II, III, IV, and V.)*                           

        **Mucocutaneous** *(Check below [and]{.underline} complete Sections 
        III, IV, and VI.)*                                                  

        **\_\_\_ Mucous Membrane \_\_\_ Skin**                              

        **Bite** *(Complete Sections III, IV, and VI.)*                     

                                                                            
  -- -- ------------------------------------------------------------------- --

###  {#section-35}

### Section II. Needle/Sharp Device Information 

*(If exposure was [percutaneous]{.underline}, provide the following
information about the device involved.)*

<table style="width:100%;">
<colgroup>
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 14%" />
<col style="width: 2%" />
<col style="width: 19%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 24%" />
<col style="width: 0%" />
<col style="width: 0%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"><h1 id="name-of-device">Name of device:</h1></td>
<td colspan="11"><h1 id="section-36"></h1></td>
<td><h1 id="section-37"></h1></td>
<td><h1 id="section-38"></h1></td>
<td colspan="3"><h1 id="unknownunable-to-determine">Unknown/Unable to
determine</h1></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="4"><h1 id="section-39"></h1></td>
<td colspan="10"><h1 id="section-40"></h1></td>
<td><h1 id="section-41"></h1></td>
<td><h1 id="section-42"></h1></td>
<td colspan="3"><h1 id="section-43"></h1></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5"><strong>Brand/manufacturer:</strong></td>
<td colspan="9"></td>
<td></td>
<td></td>
<td colspan="3"><h1 id="unknownunable-to-determine-1">Unknown/Unable to
determine</h1></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5"></td>
<td colspan="9"></td>
<td></td>
<td></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="19"><strong>Did the device have a sharps injury prevention
feature, i.e., a “safety device”?</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td><h1 id="section-44"></h1></td>
<td colspan="4"><h1 id="yes">Yes</h1></td>
<td><h1 id="section-45"></h1></td>
<td><h1 id="no">No</h1></td>
<td colspan="2"><h1 id="section-46"></h1></td>
<td colspan="2"><h1 id="section-47"></h1></td>
<td colspan="6"><h1 id="unknownunable-to-determine-2">Unknown/Unable to
determine</h1></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td><h1 id="section-48"></h1></td>
<td colspan="4"><h1 id="section-49"></h1></td>
<td><h1 id="section-50"></h1></td>
<td><h1 id="section-51"></h1></td>
<td colspan="2"><h1 id="section-52"></h1></td>
<td colspan="2"><h1 id="section-53"></h1></td>
<td colspan="6"><h1 id="section-54"></h1></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="20"><h4 id="if-yes-when-did-the-injury-occur">If yes, when
did the injury occur?</h4></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="20"><h4 id="section-55"></h4></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td><h1 id="section-56"></h1></td>
<td colspan="7"><h1
id="before-activation-of-safety-feature-was-appropriate">Before
activation of safety feature was appropriate</h1></td>
<td colspan="2"><h1 id="section-57"></h1></td>
<td colspan="2"><h1 id="section-58"></h1></td>
<td colspan="6"><h1 id="safety-feature-failed-after-activation">Safety
feature failed after activation</h1></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td></td>
<td colspan="7"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td></td>
<td colspan="7">During activation of the safety feature</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6">Safety feature not activated</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td></td>
<td colspan="7"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td></td>
<td colspan="7">Safety feature improperly activated</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6">Other: __________________________________</td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="18"><strong>Describe what happened with the safety feature,
e.g., why it failed or why it was not activated:</strong></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="5"></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="22"></td>
</tr>
</tbody>
</table>

Section III. Employee Narrative *(Optional)*

  ------------------------------------------------ ----------------------
  Describe how the exposure occurred and how it    
  might have been prevented:                       

                                                   

                                                   

                                                   
  ------------------------------------------------ ----------------------

[**NOTE:** This is not a CDC or OSHA form.]{.underline} This form was
developed by CDC to help healthcare facilities collect detailed exposure
information that is specifically useful for the facilities' prevention
planning. [Information on this page (#1)]{.underline} [may]{.underline}
meet OSHA sharps injury documentation requirements and can be copied and
filed for purposes of maintaining a separate sharps injury log.
[Procedures for maintaining employee confidentiality must be
followed.]{.underline}

**Section IV. Exposure and Source Information**

A. Exposure Details: *(Check all that apply.)*

> **1. Type of fluid or material (For body fluid exposures
> [only]{.underline}, check which fluid in adjacent box.)**

+---+-------------------------------------------------------------------+
|   | > Blood/blood products                                            |
+---+-------------------------------------------------------------------+
|   |                                                                   |
+---+-------------------------------------------------------------------+
|   | > Visibly bloody body fluid\*                                     |
+---+-------------------------------------------------------------------+
|   |                                                                   |
+---+-------------------------------------------------------------------+
|   | > Non-visibly bloody body fluid**\***                             |
+---+-------------------------------------------------------------------+
|   |                                                                   |
+---+-------------------------------------------------------------------+
|   | > Visibly bloody solution (e.g., water used to clean a blood      |
|   | > spill)                                                          |
+---+-------------------------------------------------------------------+

2.  **Body site of exposure.** *(Check all that apply.)*

  -- ----------------- -- ---------------- -- ----------------------------------------------------- -- -------------
     Hand/finger          Eye                 Mouth/nose                                               Face

                                                                                                       

     Arm                  Leg                 Other (Describe:                                         
                                              \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)      
  -- ----------------- -- ---------------- -- ----------------------------------------------------- -- -------------

3.  **If percutaneous exposure:**

**Depth of injury** *(Check only one.)*

+---+--------------------------------------------------------------------+
|   | > Superficial (e.g., scratch, no or little blood)                  |
+---+--------------------------------------------------------------------+
|   |                                                                    |
+---+--------------------------------------------------------------------+
|   | > Moderate (e.g., penetrated through skin, wound bled)             |
+---+--------------------------------------------------------------------+
|   |                                                                    |
+---+--------------------------------------------------------------------+
|   | > Deep (e.g., intramuscular penetration)                           |
+---+--------------------------------------------------------------------+
|   |                                                                    |
+---+--------------------------------------------------------------------+
|   | > Unsure/Unknown                                                   |
+---+--------------------------------------------------------------------+

  ---------------------------------- -- --------- -- ------- -- ----------------
  **Was blood visible on device         Yes          No         Unsure/Unknown
  before exposure?**                                            

  ---------------------------------- -- --------- -- ------- -- ----------------

4.  **If mucous membrane or skin exposure:** *(Check only one.)*

######  Approximate volume of material

+---+--------------------------------------------------------------------+
|   | > Small (e.g., few drops)                                          |
+---+--------------------------------------------------------------------+
|   |                                                                    |
+---+--------------------------------------------------------------------+
|   | > Large (e.g., major blood splash)                                 |
+---+--------------------------------------------------------------------+

  ---------------------------------- -- --------- -- ------- -- ----------------
  **If skin exposure, was skin          Yes          No         Unsure/Unknown
  intact?**                                                     

  ---------------------------------- -- --------- -- ------- -- ----------------

# B. Source Information

  ----------------------------------- -- --------- -- ------- -- ----------------
  **1. Was the source individual         Yes          No         Unsure/Unknown
  identified?**                                                  

  ----------------------------------- -- --------- -- ------- -- ----------------

**2. Provide the serostatus of the source patient for the following
pathogens.**

<table style="width:100%;">
<colgroup>
<col style="width: 28%" />
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="3"><strong>Positive</strong></td>
<td></td>
<td colspan="3"><strong>Negative</strong></td>
<td></td>
<td colspan="3"><strong>Refused</strong></td>
<td></td>
<td colspan="3"><strong>Unknown</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="2"><h4 id="hiv-antibody">HIV Antibody</h4></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"><blockquote>
<p>HCV Antibody</p>
</blockquote></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"><blockquote>
<p>HbsAg</p>
</blockquote></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

> **3. If known, when was the serostatus of the source determined?**

+---+--------------------------------------------------------------------+
|   | > Known at the time of exposure                                    |
+---+--------------------------------------------------------------------+
|   |                                                                    |
+---+--------------------------------------------------------------------+
|   | > Determined through testing at the time of or soon after the      |
|   | > exposure                                                         |
+---+--------------------------------------------------------------------+

**Section V. Percutaneous Injury Circumstances**

**A. What device or item caused the injury?**

+---+------------------------------------------------------------------+
| # |                                                                  |
|   |                                                                  |
| H |                                                                  |
| o |                                                                  |
| l |                                                                  |
| l |                                                                  |
| o |                                                                  |
| w |                                                                  |
| - |                                                                  |
| b |                                                                  |
| o |                                                                  |
| r |                                                                  |
| e |                                                                  |
|   |                                                                  |
| n |                                                                  |
| e |                                                                  |
| e |                                                                  |
| d |                                                                  |
| l |                                                                  |
| e |                                                                  |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Hypodermic needle                                                |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | \_\_ Attached to syringe \_\_ Attached to IV tubing              |
|   |                                                                  |
|   | \_\_ Unattached                                                  |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Prefilled cartridge syringe needle                               |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Winged steel needle (i.e., butterfly^R^ type devices)            |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | \_\_ Attached to syringe, tube holder, or IV tubing              |
|   |                                                                  |
|   | \_\_ Unattached                                                  |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | IV stylet                                                        |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Phlebotomy needle                                                |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Spinal or epidural needle                                        |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Bone marrow needle                                               |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Biopsy needle                                                    |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Huber needle                                                     |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Other type of hollow-bore needle (type: \_\_\_\_\_\_\_\_\_\_)    |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Hollow-bore needle, type unknown                                 |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
| # |                                                                  |
| # |                                                                  |
| # |                                                                  |
| # |                                                                  |
|   |                                                                  |
| S |                                                                  |
| u |                                                                  |
| t |                                                                  |
| u |                                                                  |
| r |                                                                  |
| e |                                                                  |
|   |                                                                  |
| n |                                                                  |
| e |                                                                  |
| e |                                                                  |
| d |                                                                  |
| l |                                                                  |
| e |                                                                  |
+---+------------------------------------------------------------------+
|   | Suture needle                                                    |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
| # |                                                                  |
|   |                                                                  |
| G |                                                                  |
| l |                                                                  |
| a |                                                                  |
| s |                                                                  |
| s |                                                                  |
+---+------------------------------------------------------------------+
|   | Capillary tube                                                   |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Pipette (glass)                                                  |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Slide                                                            |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Specimen/test/vacuum                                             |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Other:                                                           |
|   | \_\_\_\_                                                         |
|   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+

+---+------------------------------------------------------------------+
| * |                                                                  |
| * |                                                                  |
| O |                                                                  |
| t |                                                                  |
| h |                                                                  |
| e |                                                                  |
| r |                                                                  |
| s |                                                                  |
| h |                                                                  |
| a |                                                                  |
| r |                                                                  |
| p |                                                                  |
| o |                                                                  |
| b |                                                                  |
| j |                                                                  |
| e |                                                                  |
| c |                                                                  |
| t |                                                                  |
| s |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Bone chip/chipped tooth                                          |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Bone cutter                                                      |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Bovie electrocautery device                                      |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Bur                                                              |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Explorer                                                         |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Extraction forceps                                               |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Elevator                                                         |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Histology cutting blade                                          |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Lancet                                                           |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Pin                                                              |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Razor                                                            |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Retractor                                                        |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Rod (orthopaedic applications)                                   |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Root canal file                                                  |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Scaler/curette                                                   |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Scalpel blade                                                    |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Scissors                                                         |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Tenaculum                                                        |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Trocar                                                           |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Wire                                                             |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Other type of sharp object                                       |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
|   | Sharp object, type unknown                                       |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+
| # |                                                                  |
| # |                                                                  |
| # |                                                                  |
| # |                                                                  |
|   |                                                                  |
| O |                                                                  |
| t |                                                                  |
| h |                                                                  |
| e |                                                                  |
| r |                                                                  |
|   |                                                                  |
| d |                                                                  |
| e |                                                                  |
| v |                                                                  |
| i |                                                                  |
| c |                                                                  |
| e |                                                                  |
|   |                                                                  |
| o |                                                                  |
| r |                                                                  |
|   |                                                                  |
| i |                                                                  |
| t |                                                                  |
| e |                                                                  |
| m |                                                                  |
+---+------------------------------------------------------------------+
|   | Other:                                                           |
|   | \_\_\_                                                           |
|   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+---+------------------------------------------------------------------+

**B. Purpose or procedure for which sharp item was used or intended.**

*(Check [one procedure]{.underline} type and complete information in
corresponding box as applicable.)*

  --- -------------------------------------------------------------------
      Establish intravenous or arterial access (Indicate type of line.)

      

      Access established intravenous or arterial line

      (Indicate type of line [and]{.underline} reason for line access.)
  --- -------------------------------------------------------------------

  --- ----------------------------------------------------- --------------
      Injection through skin or mucous membrane             

      (Indicate type of injection.)                         

                                                            

      Obtain blood specimen (through skin)                  

      (Indicate method of specimen collection.)             

                                                            

      Other specimen collection                             

                                                            

      Suturing                                              

                                                            

      Cutting                                               

                                                            

      Other procedure                                       

                                                            

      Unknown                                               
  --- ----------------------------------------------------- --------------

C. When and how did the injury occur? (From the left hand side of page,
select the point during or after use that most closely represents when
the injury occurred. In the corresponding right hand box, select *one or
two* circumstances that reflect how the injury happened.)

  ---- ------------------------- -----------------------------------------
                                 

                                 

                                 

                                 

                                 

                                 

       During use of the item    

                                 

       After use, before         
       disposal of item          

                                 

       During or after disposal  
       of item                   

                                 

       Other (Describe):         

                                 

                                 

                                 

                                 

       Unknown                   
  ---- ------------------------- -----------------------------------------

+---+---+---------------------------------------------------------------+
| * |   |                                                               |
| * |   |                                                               |
| S |   |                                                               |
| e |   |                                                               |
| l |   |                                                               |
| e |   |                                                               |
| c |   |                                                               |
| t |   |                                                               |
| o |   |                                                               |
| n |   |                                                               |
| e |   |                                                               |
| o |   |                                                               |
| r |   |                                                               |
| t |   |                                                               |
| w |   |                                                               |
| o |   |                                                               |
| c |   |                                                               |
| h |   |                                                               |
| o |   |                                                               |
| i |   |                                                               |
| c |   |                                                               |
| e |   |                                                               |
| s |   |                                                               |
| : |   |                                                               |
| * |   |                                                               |
| * |   |                                                               |
+---+---+---------------------------------------------------------------+
|   |   |                                                               |
+---+---+---------------------------------------------------------------+
|   |   | Patient moved and jarred device                               |
+---+---+---------------------------------------------------------------+
|   |   | While inserting needle/sharp                                  |
+---+---+---------------------------------------------------------------+
|   |   | While manipulating needle/sharp                               |
+---+---+---------------------------------------------------------------+
|   |   | While withdrawing needle/sharp                                |
+---+---+---------------------------------------------------------------+
|   |   | Passing or receiving equipment                                |
+---+---+---------------------------------------------------------------+
|   |   | Suturing                                                      |
+---+---+---------------------------------------------------------------+
|   |   | Tying sutures                                                 |
+---+---+---------------------------------------------------------------+
|   |   | Manipulating suture needle in holder                          |
+---+---+---------------------------------------------------------------+
|   |   | Incising                                                      |
+---+---+---------------------------------------------------------------+
|   |   | Palpating/Exploring                                           |
+---+---+---------------------------------------------------------------+
|   |   | Collided with co-worker or other during procedure             |
+---+---+---------------------------------------------------------------+
|   |   | Collided with sharp during procedure                          |
+---+---+---------------------------------------------------------------+
|   |   | Sharp object dropped during procedure                         |
+---+---+---------------------------------------------------------------+
|   |   |                                                               |
+---+---+---------------------------------------------------------------+
|   |   |                                                               |
+---+---+---------------------------------------------------------------+
| * |   |                                                               |
| * |   |                                                               |
| S |   |                                                               |
| e |   |                                                               |
| l |   |                                                               |
| e |   |                                                               |
| c |   |                                                               |
| t |   |                                                               |
| o |   |                                                               |
| n |   |                                                               |
| e |   |                                                               |
| o |   |                                                               |
| r |   |                                                               |
| t |   |                                                               |
| w |   |                                                               |
| o |   |                                                               |
| c |   |                                                               |
| h |   |                                                               |
| o |   |                                                               |
| i |   |                                                               |
| c |   |                                                               |
| e |   |                                                               |
| s |   |                                                               |
| : |   |                                                               |
| * |   |                                                               |
| * |   |                                                               |
+---+---+---------------------------------------------------------------+
|   |   |                                                               |
+---+---+---------------------------------------------------------------+
|   |   | Handling equipment on a tray or stand                         |
+---+---+---------------------------------------------------------------+
|   |   | Transferring specimen into specimen container                 |
+---+---+---------------------------------------------------------------+
|   |   | Processing specimens                                          |
+---+---+---------------------------------------------------------------+
|   |   | Passing or transferring equipment                             |
+---+---+---------------------------------------------------------------+
|   |   | Recapping (missed or pierced cap)                             |
+---+---+---------------------------------------------------------------+
|   |   | Cap fell off after recapping                                  |
+---+---+---------------------------------------------------------------+
|   |   | Disassembling device or equipment                             |
+---+---+---------------------------------------------------------------+
|   |   | Decontamination/processing of used equipment                  |
+---+---+---------------------------------------------------------------+
|   |   | During clean-up                                               |
+---+---+---------------------------------------------------------------+
|   |   | In transit to disposal                                        |
+---+---+---------------------------------------------------------------+
|   |   | Opening/breaking glass containers                             |
+---+---+---------------------------------------------------------------+
|   |   | Collided with co-worker/other person                          |
+---+---+---------------------------------------------------------------+
|   |   | Collided with sharp after procedure                           |
+---+---+---------------------------------------------------------------+
|   |   | Sharp object dropped after procedure                          |
+---+---+---------------------------------------------------------------+
|   |   | Struck by detached IV line needle                             |
+---+---+---------------------------------------------------------------+
|   |   |                                                               |
+---+---+---------------------------------------------------------------+
|   |   |                                                               |
+---+---+---------------------------------------------------------------+
| * |   |                                                               |
| * |   |                                                               |
| S |   |                                                               |
| e |   |                                                               |
| l |   |                                                               |
| e |   |                                                               |
| c |   |                                                               |
| t |   |                                                               |
| o |   |                                                               |
| n |   |                                                               |
| e |   |                                                               |
| o |   |                                                               |
| r |   |                                                               |
| t |   |                                                               |
| w |   |                                                               |
| o |   |                                                               |
| c |   |                                                               |
| h |   |                                                               |
| o |   |                                                               |
| i |   |                                                               |
| c |   |                                                               |
| e |   |                                                               |
| s |   |                                                               |
| : |   |                                                               |
| * |   |                                                               |
| * |   |                                                               |
+---+---+---------------------------------------------------------------+
|   |   |                                                               |
+---+---+---------------------------------------------------------------+
|   |   | Placing sharp in container:                                   |
+---+---+---------------------------------------------------------------+
|   |   | \_\_ Injured by sharp being disposed                          |
|   |   |                                                               |
|   |   | \_\_ Injured by sharp already in container                    |
+---+---+---------------------------------------------------------------+
|   |   | While manipulating container                                  |
+---+---+---------------------------------------------------------------+
|   |   | Over-filled sharps container                                  |
+---+---+---------------------------------------------------------------+
|   |   | Punctured sharps container                                    |
+---+---+---------------------------------------------------------------+
|   |   | Sharp protruding from open container                          |
+---+---+---------------------------------------------------------------+
|   |   | Sharp in unusual location:                                    |
+---+---+---------------------------------------------------------------+
|   |   | \_\_ In trash                                                 |
|   |   |                                                               |
|   |   | \_\_ In linen/laundry                                         |
|   |   |                                                               |
|   |   | \_\_ Left on table/tray                                       |
|   |   |                                                               |
|   |   | \_\_ Left in bed/mattress                                     |
|   |   |                                                               |
|   |   | \_\_ On floor                                                 |
|   |   |                                                               |
|   |   | \_\_ In pocket/clothing                                       |
|   |   |                                                               |
|   |   | \_\_ Other unusual location                                   |
+---+---+---------------------------------------------------------------+
|   |   | Collided with co-worker or other person                       |
+---+---+---------------------------------------------------------------+
|   |   | Collided with sharp                                           |
+---+---+---------------------------------------------------------------+
|   |   | Sharp object dropped                                          |
+---+---+---------------------------------------------------------------+
|   |   | Struck by detached IV line needle                             |
+---+---+---------------------------------------------------------------+
|   |   |                                                               |
+---+---+---------------------------------------------------------------+

**Section VI. Mucous Membrane Exposures Circumstances**

**A. What barriers were used by worker at the time of the exposure?**
*(Check all that apply.)*

  -- --------- -- --------- -- ------------ -- --------- -- -------- -- -----------
     Gloves       Goggles      Eyeglasses      Face         Mask        Gown
                                               Shield                   

  -- --------- -- --------- -- ------------ -- --------- -- -------- -- -----------

**B. Activity/Event when exposure occurred** *(Check one.)*

  -- ----------------------------------------------------------------------------------------------------------------
     Patient spit/coughed/vomited

     

     Airway manipulation (e.g., suctioning airway, inducing sputum)

     

     Endoscopic procedure

     

     Dental procedure

     

     Tube placement/removal/manipulation (e.g., chest, endotracheal, NG, rectal, urine catheter)

     

     Phlebotomy

     

     IV or arterial line insertion/removal/manipulation

     

     Irrigation procedure

     

     Vaginal delivery

     

     Surgical procedure (e.g., all surgical procedures including C-section)

     

     Bleeding vessel

     

     Changing dressing/wound care

     

     Manipulating blood tube/bottle/specimen container

     

     Cleaning/transporting contaminated equipment

     

     Other:
     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

     

     Unknown
  -- ----------------------------------------------------------------------------------------------------------------

  -- --------------- ------------ --------------------- -- --------------------------- --
                                                                                       

     **Comments:**                                                                     

                                                                                       

                                                                                       

                                                                                       

                                                                                       

                                                                                       

                                                                                       

                                                                                       
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