Form J: Exposure Incident Investigation Report

EXPOSURE INCIDENT INVESTIGATION FORM

Employee Name Address

Date of Incident Time of Incident

Location ______

Potentially Infectious Materials Involved

Type ___ Source ______

Circumstances (work being performed, etc.)
____________ _

_____________________________________________________________ __


How Incident Was Caused (accident, equipment malfunction, etc.)
_____________________________________

_


Personal Equipment Being Used
_____________


Actions Taken (decontamination, clean-up, reporting, etc.)
_______________________________


Recommendations for Avoiding Repetition ____________ ______

__________________________________________________________________


Signature of Employee ____ Date_ ______


Signature of Exposure Control Plan Administrator
___________ _____________


Date of Review