Fillable Exposure Incident Report Form (California State University Channel Islands)

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Exposure Incident Report Form (California State University Channel Islands)

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EXPOSURE INCIDENT REPORT FORM
CSUCI Bloodborne Pathogen Exposure Program
Provide a description of the exposed employee's duties as they relate to the exposure incident:
(Attach additional information, if necessary.)
How did the exposure incident occur? Please provide an explanation of the routes(s) of exposure and
the circumstances under which the exposure incident occurred:
Send to Environment, Health, Safety & Risk Management
EMPLOYEE SIGNATURE
DATE
Report Date
Employee Last Name
Employee First Name
Incident Date
Position/Title
Alternate Phone Number
Primary Phone Number
Employee ID Number
Incident Location
Supervisor's Name
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Exposure Incident Report Form (California State University Channel Islands)

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Completed 18 July 2020

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