Exposure Incident Report {Evolve Icon}
Name of Exposed Person: _________________________
Job Classification: ________________________________
Name of Employer: ______________________________
Date of Exposure: ____________________ Time: ______
Description of the Incident: ________________________________________________________
What barriers were used by exposed person during the incident? ________________________________________________________
________________________________________________________
Describe corrective measures to minimize possible recurrence: ________________________________________________________
Was source (patient) sent for medical evaluation? Yes _______________ No _____________
Patient’s name: __________________________________Comments: ________________________________________________________
Was exposed person sent for medical evaluation? Yes _______________ No _____________
Comments: ________________________________________________________
Was the exposed person informed by the evaluating physician of the results of the medical evaluation as required by OSHA? Yes _______________ No __________
Was the employer informed by the evaluating physician that the exposed person was evaluated medically as required by OSHA? Yes _______________ No ________________________________________________________
Signature of exposed person Date________________________________________