Exposure Report (Sharps Injury Log. 29 CFR 1904)
Wichita State University –Student Health Services 1845 Fairmount Wichita, KS 67260-0092
Phone number: 316-978-4792 Fax number: 316-978-3517
INFORMATION ABOUT EXPOSURE: Circle one
Student Staff/Faculty Department
Name myWSU#
Address Phone Number
Where exposure occurred (circle one): On campus Off ca
mpus. Location
History of Hepatitis B vaccinations? (circle one)
_________________________________________________________________________________________
__________________________________________________________________________________________
________________
______________________________________________ __________________________
_____________________________________________ _____________________
(mailing address) (city/state/zip)
______________________
Yes No Dates: __________
Previous results of Hepatitis B antibody test (HBsAb) _________ Date of Last Tetanus?______________
Details of Procedure:
Date and time of exposure: _______________________________Date reported to SHS___________________
Give details of procedure being performed: ______________________________________________________
Where and how did exposure occur: ____________________________________________________________
Was exposure related to a sharp device: Yes No If yes, type/brand of sharp device: ____________________
In the course of handling the device, how and when did exposure occur: _______________________________
Details of exposure:
Type and amount of fluid or material:___________________________________________________________
Severity of exposure:
1. Percutaneous: Yes No Depth of injury___________ Fluid injected: Yes No
2. Skin/Mucous Membrane: Yes No Estimated volume of material________________________________
Duration of contact: _________Condition of skin (e.g. chapped, abraded or intact):_______________________
Details of Exposure Source: (Individual you were exposed to)
Name:__________________________________________________ Age______Phone number_____________
Address:__________________________________________________________________________________
History of source individual:
Is source a known HIV infected person: Yes No If yes, stage of disease____________________
Antiretroviral therapy: Yes No Viral load, if known: ______________________________
Hepatitis B Surface Antigen (HBsAg) status: _____________________________________________________
Hepatitis C virus (HCV) status known?_________________________________________________________
For Clinic Use Only: Diagnosis Code: __________________
(If form needs to be faxed to student) Date
Form
Faxed:______________Location__________________
Lab work
–
please circle if done on or off campus.
Source patient
(On Off
Exposed patient
(On Off
Off campus lab done at________________________
Patient Counseling:
1. Hep B, Hep C, & HIV ___________
2. Risk of infection
___________
3. All lab test results ___________
4. Treatment needs ___________
5. Follow up
___________
6. Protection ___________
Off campus referral details, if needed ________________________________________________________
Nurse Signature:______________________________________________________Date:__________________
Initial Form Date: 1/92 Last update: 02/20
click to sign
signature
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