You must have JavaScript enabled to use this form. Please complete a log for each employee exposure incident involving a sharp. Institution Department Address City State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Date filled out By email Phone Facility Injury ID Date of injury Time of injury Optional Male Female Age Description of the exposure incident Job Classification MD Nurse Medical Assistant Phlebotomist/Lab Tech Housekeeper/Laundry Student Other If "Other" please describe here Department/Location Patient room Clinical laboratory Medical clinic Service/utility area Restroom Other… Enter other… If "Other" please describe here Body Part: (check all that apply) Finger Face/head Hand Torso Arm Leg Other Other… Enter other… If "Other" please describe here Procedure Drawing blood Cutting Injection, through skin Suturing Start IV/set up heparin lock Other… Enter other… If "Other" please describe here Identify Sharp Involved: Type Brand Model Example: 18g needle/ABC Medical/”no stick” syringe Did the device being used have engineered sharps injury protection? Yes No Don't Know Was the protective mechanism activated? Yes-fully Yes-partially No Did the exposure incident occur? Before During After Activation Did the exposure incident occur During use of sharp Between steps of a multi-step procedure After use and before disposal of sharp While disassembling While putting sharp into disposal container Sharp in inappropriate place (table, trash, etc) Other… Enter other… If "Other" please describe here Exposed Employee If sharp had no engineered sharps injury protection, do you have an opinion that such a mechanism could have prevented the injury? Yes No Explain Do you have an opinion that any other engineering, administrative or work practice control could have prevented the injury? Yes No Explain