SHARPS INJURY LOG
CSUCI Bloodborne Pathogen Exposure Program
NO
Copy to Environment, Safety, Risk Management
5/09
EMPLOYEE SIGNATURE
DATE
Did the sharp have an engineered injury protection mechanism?
YES
If yes, was the protection mechanism activated?
NO
YES
If the sharp did not have engineered injury protection, in the injured employee's opinion, would such a mechanism
have prevented the injury?
NO
YES
What other engineering, administrative or work practice controls might have prevented the injury?
Last Name of Employee
First Name of Employee
Position/Title
Department
Date and time of sharps incident
Type and brand of sharp
Department or work area where incident occurred
Procedure the employee was performing at the time of the incident
How the incident occurred
Body part involved
If yes, did the injury occur before, during or after the protective mechanism was activated?
Why or why not?
