Fillable Student Exposure Form (Montana Tech)

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Student Exposure Form (Montana Tech)

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1300 W. Park Street | Butte, MT 59701 | mtech.edu | 406.496.4463
Student Exposure Incident Form
Student Name:
Student ID #:
Date of incident:
Department/building:
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 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? Check all that apply
Gloves Gown/apron Mask Eyewear CPR shield None Other (specify) ________________
Dates of HBV vaccinations:
Employee signature:
Date:
Instructor/Supervisor signature:
Date:
Signature of person preparing report:
Date:
Follow-up
Date
Student referred to physician of choice
Seen by: Office ER Pro-Med Student Health Center
Declined to be seen
Other comments:
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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Student Exposure Form (Montana Tech)

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Completed 24 July 2020

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