BYU-Idaho Bloodborne Incident Report Form

Fill in all of the boxes as much as possible. 


NOTE:  FAILURE TO COMPLETE ALL SECTIONS OF THIS FORM MAY DELAY CLAIM AND/OR PAYMENT OF BENEFITS.

Needle StickOther Exposure Incident Date  
Full Name of Injured Individual  
Email Address of Injured:  
Local Address      
                            Street & Number                         City / State                     Zip Code

Telephone     Date of Birth   
                        Home                       Work

Age  Sex         BYU-I #   Marital Status    (Single, Married, Divorced, Widowed)  
Staff      Administrative      Faculty       Student  
 Department   Position Title    
 Is this a work related incident?     Yes      No 
 Is the victim current on vaccinations?     Yes      No 
Time of Incident  AM      PM 
Date supervisor notified   Time supervisor is notified
Name of Supervisor/Instructor 
Location of Accident or Exposure 
                                                         (Building, room, off-campus address, etc.)

What types of potentially infectious materials were involved?

How did the Incident Occur?  (Give as much detail as possible. Name tool, object, behavior, etc. that caused injury)

                        
 Did Individual Receive Medical Care?   Yes
      No       First Aid Only

Where was medical treatment received?  None    Health Center    Hospital    Physician 
Attending Physician or Hospital   
Describe any Actions Taken or Treatment Given as a result of the incident: 

Name of Witness  Contact Person 
Date report submitted  Contact Phone #

What could have been done to prevent the incident? (to be filled out by the supervisor):


NOTICE:    IMMEDIATELY REPORT ALL NEEDLE STICKS TO UNIVERSITY SAFETY OFFICE.  

                                                        (Save a copy for your records)