Fillable Employee Incident Form (Montana Tech)

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Employee Incident Form (Montana Tech)

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The Employee Incident Form (Montana Tech) form is 1 page long and contains:

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1300 W. Park Street | Butte, MT 59701 | mtech.edu | 406.496.4463
Employee Occupational Exposure Incident Form
Employee Name:
Employee ID #:
Date:
Department/building:
Job title:
Date of incident:
Date reported:
Type of exposure:
Human bite
Blood/body fluid splash
Open wound, scratch, or abrasions contaminated with blood/body fluid/urine/stool
Puncture or scratch from sharp object
Needle stick following venipuncture
Needle stick from IVP or VIPB
Needle stick following injection
Other (describe)____________________________________________________________________
Describe exposure incident in detail:
What actions were taken immediately following the incident?
What precautions were in use at the time of the incident?
Gloves Gown/apron Mask Eyewear CPR shield None Other (specify) ________________
Dates of HBV vaccinations:
Employee signature:
Date:
Supervisor signature:
Date:
Follow-up
Date
Employee referred to physician of choice
Seen by: Office ER Pro-Med Declined to be seen
Employee’s blood drawn? YES NO
Employee offered HIV testing? YES NO
Accepted Declined
This document must be printed after completion, signed, and sent to mcameron@mtech.edu or brought to EHS
office CBB 003.
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Employee Incident Form (Montana Tech)

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Completed 26 July 2020

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