BLOODBORNE PATHOGENS
EXPOSURE INCIDENT REPORT
EXPOSED WORKER
Name ___________________________ Position___________________Phone__________
Occurrence Date______________________________ Reported Date_________________
HBV Vaccination Status _____________________________________________________
Consent: HIV testing_______________________ HBV testing_____________________
SOURCE INDIVIDUAL
Name _________________________ Position____________________Phone_________
Consent: HIV testing_____________________ HBV testing_______________________
DESCRIPTION OF INCIDENT
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