BLOODBORNE PATHOGENS EXPOSURE INCIDENT REPORT
CCS employee exposure to blood and/or other potentially infectious material.
Copy distribution: 1) Human Resources, MS 1004 2) Environmental Health and Safety, MS 1016 3) Supervisor 4) Exposed employee 5) Take to health care provider
CCS 1295 (Rev. 03/18) Marketing and Public Relations
This report is to be completed as soon as possible after the exposure incident. Please print legibly.
Exposure Incident: Contact with blood/body fluids or other potentially infectious materials on your skin, in your eye, nose,
or mouth or parenteral contact (a piercing of the mucous membranes or the skin barrier, e.g., needlesticks, human bites,
cuts, and abrasions) with blood or other body fluids resulting from the performance of an employee’s duties.
1. Name of exposed employee
2. Date of incident Time incident occurred: Hour ❒ AM ❒ PM
3. Unit: ❒ SCC ❒ SFCC Work phone
4. Location where incident occurred: ❒ SCC ❒ SFCC
5. Building Room number
6. Other location
7. Describe route(s) of exposure and circumstances under which the exposure incident occurred:
8. Body surface area(s) exposed
9. Type and amount of fluid or material
10. Severity of exposure: (extent and duration of contact)
11. Exposure source, if known (name of individual) Phone
12. Your Hepatitis B vaccination status: ❒ None ❒ Received ❒ Immunization date
I acknowledge that a confidential medical evaluation and follow-up is available to me from a health care professional within twenty-four
(24) hours of this incident as part of the post-exposure process to determine my immune status to the hepatitis B virus and to receive
baseline information to determine if exposure to the HIV virus has occurred. I understand that this incident should be reported to my
health care provider as an on-the-job injury.
Exposed employee’s signature
Date
Supervisor’s signature Date
Health care provider Date
