Report • CampusOptics

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Name* Required

Additional Location Details

Exact Location

Loading…

Name and Title of Individual involved/injured if applicable

Address and Phone number of Individual Injured if applicable

Circumstances Leading to Incident

Description of the Incident

Was the incident reported to a supervisor or health safety officer?

Was the incident reported immediately after occurrence?

Time elapsed between the exposure and reporting?

Type of device involved

Type of exposure: catagory

Was the needle used on a patient before the incident occured?

Was the needle attached to a syringe at the time of the incident?

Was PPE worn at time of incident?

If PPE was worn, what type of PPE was used?

If PPE was used, did the incident occur through the PPE?

Part of body affected

Source of exposure:

Was the device visibly contaminated with other potentially infectious material?

Was there visible blood on device?

First aid measures taken immediately after the exposure

Was the incident evaluated by a healthcare professional?

Name and contact information of the medical facility or healthcare provider

Was first aid administered immediately after the incident?

Are there any witnesses to the incident?

Add files to upload as supporting documentation along with your incident.