Exposure to Blood/Body Fluids Page 2 of 7 Section II – Percutaneous Injury 1. *Was the needle or sharp object visibly contaminated with blood prior to exposure? □ Y □ N 2. Depth of the injury: (Check one) □ Superficial, surface scratch □ Deep puncture or wound □ Moderate, penetrated skin □ Unknown 3. What needle or sharp object caused the injury (Check one) □ Device (select one) □ Non-device sharp object (specify): ___________________ □ Unknown sharp object Hollow-bore needle □ Arterial blood collection device □ Biopsy needle □ Bone marrow needle □ Hypodermic needle, attached to syringe □ Hypodermic needle, attached to IV tubing □ Unattached hypodermic needle □ IV catheter – central line □ IV catheter – peripheral line □ Huber needle □ Prefilled cartridge syringe □ IV stylet □ Spinal or epidural needle □ Hemodialysis needle □ Dental aspirating syringe w/ needle □ Vacuum tube holder/needle □ Winged-steel (Butterfly™ type) needle □ Hollow-bore needle, type unknown □ Other hollow-bore needle Suture needle □ Suture needle Other solid sharps □ Bone cutter □ Bur □ Electrocautery device □ Elevator □ Explorer □ Extraction forceps □ File □ Lancet □ Microtome blade □ Pin □ Razor □ Retractor □ Rod (orthopedic) □ Scaler/curette □ Scalpel blade □ Scissors □ Tenaculum □ Trocar □ Wire Glass □ Capillary tube □ Blood collection tube □ Medication ampule/vial/bottle □ Pipette □ Slide □ Specimen/test/vacuum tube Plastic □ Capillary tube □ Blood collection tube □ Specimen/test/vacuum tube Non-sharp safety device □ Blood culture adapter □ Catheter securement device □ IV delivery system □ Other known device (specify): _________________________________ 4. Manufacturer and Model: _____________________________________
Exposure to Blood/Body Fluids Page 5 of 7 Section III – Mucous Membrane and/or Skin Exposure 1. Estimate the amount of blood/body fluid exposure: (Check one) □ Small (<1 tsp or 5cc) □ Large (> ¼ cup or 50cc) □ Moderate (>1 tsp and up to ¼ cup, or 6-50 cc) □ Unknown 2. Activity/event when exposure occurred: (Check one) □ Airway manipulation (e.g., suctioning airway, inducing sputum) □ Patient spit/coughed/vomited □ Bleeding vessel □ Phlebotomy □ Changing dressing/wound care □ Surgical procedure (e.g., all surgical procedures including C-section) □ Cleaning/transporting contaminated equipment □ Tube placement/removal/manipulation (e.g., chest, endotracheal, NG, rectal, urine catheter) □ Endoscopic procedures □ Vaginal delivery □ IV or arterial line insertion/removal/manipulation □ Other (specify): _______________________________ □ Irrigation procedures □ Unknown □ Manipulating blood tube/bottle/specimen container 3. Barriers used by the worker at the time of exposure: (Check all that apply) □ Face shield □ Mask/respirator □ Gloves □ Other (specify): _______________________________ □ Goggles □ No barriers □ Gown Section IV – Bite 1. Wound description: (Check one) □ No spontaneous bleeding □ Tissue avulsed □ Spontaneous bleeding □ Unknown 2. Activity/event when exposure occurred: (Check one) □ During dental procedure □ Assault by patient □ During oral examination □ Other (specify): _______________________________ □ Providing oral hygiene □ Unknown □ Providing non-oral care to patient