Incident Report • CampusOptics

Reporter Info

Email* Required

Phone Number* Required

First Name* Required

Last Name* Required

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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Name and Title of Individual involved/injured if applicable* Required

Address and Phone number of Individual Injured if applicable* Required

Circumstances Leading to Incident* Required

Description of the Incident* Required

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

Was the incident reported immediately after occurrence?* Required

Time elapsed between the exposure and reporting?* Required

Type of device involved* Required

Type of exposure: catagory* Required

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

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

Was PPE worn at time of incident?* Required

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

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

Part of body affected* Required

Source of exposure:* Required

Was the device visibly contaminated with other potentially infectious material?* Required

Was there visible blood on device?* Required

First aid measures taken immediately after the exposure* Required

Was the incident evaluated by a healthcare professional?* Required

Name and contact information of the medical facility or healthcare provider* Required

Was first aid administered immediately after the incident?* Required

Are there any witnesses to the incident?* Required

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