Fillable Farmingdale SHARPS INJURY LOG

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Farmingdale SHARPS INJURY LOG

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FARMINGDALE STATE COLLEGE
ENVIRONMENTAL HEALTH & SAFETY
SHARPS INJURY LOG
Please complete a log for each employee exposure incident involving a sharp within 14 days o
f the
date the incident is reported.
Complete this form in conjunction with the Hazardous Chemical Exposure Report Form for sharps injuries
that also involve occupational chemical exposures (i.e. stuck by needle used to pipette a chemical).
Check the box that corresponds to the most appropriate answer. Type or print clearly.
Department:
Phone:
Date Completed:
Supervisor:
Supervisor
Signature:
Date Signed:
Date of Injury:(Month-Day-Year)
Time of Injury
Gender
Age
/ /
:
am pm
Male Female
Description of the exposure incident involving sharps:
Job Classification of Exposed Employee:
(Check All That Apply)
MD PA NP RN
Medical Assistant Phlebotomist/Med Tech
Custodial Plumber
Grounds Worker Police Officer
Researcher/Lab Tech Animal Care Worker
Coach/Trainer
Other
Location/Work Area Where Exposure Occurred:
(Check All
That Apply)
Exam Room Procedure Room
Urgent Care Residential Site
Athletic Field/Gym Recreation/Fit Center
Laboratory/Classroom Animal Facility
Service/Utility Area
Other:
Procedure Being Performed at Time of Incident: (Check All
That Apply)
Draw venous blood Heparin/saline flush
Draw arterial blood Cutting
Injection through skin Suturing
Start IV/set up heparin lock Handling Medical Waste
Provide First Aid/CPR
Research procedure, explain:
Other
Exposure Incident Occurred: (Check All That Apply)
During use of sharp Disassembling
Between steps of a multistep procedure
After use and before disposal of sharp
While putting sharp into disposal container
Sharp left in inappropriate place (table, bed, trash, etc.)
Other
(Check All That Apply)
Finger Face/Head
Hand Torso
Arm Leg
Other
Identify sharp involved (if known):
Type:
Brand:
Model:
e.g. 18g needle/ABC Medical, “no stick”
syringe
Did the device being used
have engineered sharps injury
protection?
Yes No Don’t know
Was the protective
mechanism activated?
Yes, Fully Yes, Partially
No
Did the exposure incident
occur?
Before During
After Activation
Exposed Employee Opinion: If sharp had no engineered
sharps injury protection, do you have an opinion that such a
mechanism could have prevented the injury?
Exposed Employee Opinion: Do you have an opinion that
any other engineering, administrative or work practice
control could have prevented the injury?
Yes No
Explain:
Yes No
Explain:
Did employee seek
medical attention?
Health Care Facility:
Health Care Personnel:
Phone:
Yes No
Sharps Injury Log must be submitted to:
Environmental Health & Safety, 135 Horton Hall, 2350 Broadhollow Road, Farmingdale, NY 11735
Phone: (631) 420-2105 Fax: (631) 420-9173 Click here for the EH&S Website:
http://www.farmingdale.edu/administration/administration-finance/environmental-health-safety/index.shtml
EHS, FSC
Rev 04/14
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Farmingdale SHARPS INJURY LOG

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Completed 21 February 2020

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