Sharps Injury/Exposure Incident Report (Clinic Safety)

(This is an occupational safety incident report, not a clinical patient encounter note. Use objective, factual language without assigning fault or blame. Time-stamp all key events. If information is missing at the time of initial reporting, enter an explicit status such as "Unknown," "Pending," "Declined," or "Not applicable" rather than leaving fields blank. Update this record as new information becomes available.)

Incident/Event Number: [unique identifier]

Report Status: [Draft / Submitted / Under Review / Closed]

Date/Time Created: [date and time]

Last Updated: [date and time]

Access Designation: Safety Report—Restricted (Source-identifying details and employee health information require additional access restrictions per policy.)

Personnel

Report completed by: [Name], [Role/Title], [Department], [Contact information], [Relationship to event: exposed worker / witness / supervisor / safety officer]

Exposed/Injured Worker: [Worker type: employee / contractor / student / volunteer], [Job title], [Department/Work unit], [Work location], [Supervisor name and contact]

Witnesses: [Names and contact information / No witnesses identified]

Incident Timing and Location

• Date of exposure: [date]
• Time of exposure: [24-hour time or AM/PM] (If estimated, note reason.)
• Date/time exposure recognized (if different): [date and time / Same as exposure time / Unknown]
• Date/time reported to supervisor: [date and time / Unknown / Pending]
• Date/time medical evaluation initiated: [date and time / Not yet performed / Pending]
• Facility/Site: [facility name]
• Department/Work Area: [department or unit]
• Specific Location: [building, floor, room number]
• Setting Type: [outpatient clinic / urgent care / lab / procedure room / home visit / other]

Exposure Description

(Begin with structured classification, then provide a concise, chronological narrative using neutral, factual wording.)

• Type of Exposure: [Percutaneous (needlestick/sharp) / Mucous membrane (eye, mouth, nose) / Non-intact skin / Intact skin / Human bite with blood exposure / Other] (Select all that apply.)
• Body Site(s) Exposed: [e.g., hand/finger, arm, face, eye]
• Exposure Fluid/Material: [Blood or blood products / Visibly bloody body fluid / Non-visibly bloody body fluid / Contaminated solution / Unknown] (Specify fluid type if known.)
• Severity Descriptors:
  • (For percutaneous) Depth: [superficial / moderate / deep / unsure]; Blood visible on device: [yes / no / unsure]
  • (For splash/skin) Volume: [small—few drops / large—major splash]; Skin intact: [yes / no / unsure]
• Procedure/Task Being Performed: [e.g., venipuncture, injection, IV access, suturing, specimen handling, equipment cleaning, other]
• Event Phase: [During patient care procedure / After use before disposal / During or after disposal / During recapping / During device disassembly / During cleanup / Contact with sharp in unexpected location / Other]
• Contributing Factors: [Patient movement / Collision with another person / Sharp dropped / Overfilled or poorly placed sharps container / Inadequate lighting or space / Time pressure or urgency / PPE failure / Communication issue / Other] (Check all that apply.)

Employee Narrative: [Chronological, factual description of how the exposure occurred, including times if known] (Required, 3–8 sentences. May include suggested system or process changes. Do not assign blame.)

Device Information

(Include for percutaneous injuries. For splash exposures, include only if a specific device contributed.)

• Device Type: [hypodermic needle / butterfly / IV stylet / phlebotomy needle / scalpel / suture needle / lancet / glass / other]
• Brand/Manufacturer: [name / Unknown / Unable to determine]
• Model/Catalog Number and Gauge: [details / Unknown]
• Hollow-bore: [Yes / No / Unknown]
• Safety-Engineered Feature:
  • Safety feature present: [Yes / No / Unknown]
  • Injury timing relative to safety feature: [Before activation was appropriate / During activation / After activation (feature failed) / Feature not activated / Improper activation / Not applicable]
  • Brief description of safety feature performance: [narrative description]
• Device Disposition: [Disposed in sharps container immediately / Disposed in sharps container later / Not properly disposed / Unknown / Retained for evaluation] (If retained, note location and chain of custody.)
• Sharps container overfilled or damaged: [Yes / No / Unknown]

PPE and Controls

• PPE in Use at Time of Exposure: [Gloves / Gown / Mask / Face shield / Goggles / Eyeglasses / Other / None] (Check all that apply.)
• Work Practice Controls: Hand hygiene before task [yes / no / unknown]; Handwashing or flush after exposure [yes / no], time: [time / Unknown]; Sharps container within arm's reach [yes / no / unknown]; Recapping performed [yes / no], method and rationale: [details / Not applicable]
• Engineering Controls: Safety-engineered device available for this task [yes / no / unknown]; If available but not used, reason: [not stocked / clinician preference / task constraints / other / Not applicable]

Immediate Response Actions

(Document all actions with times.)

• First Aid Performed:
  • Wound washed with soap and water: [time / Not performed / Not applicable]
  • Skin/mucous membrane flushed with water: [time / Not performed / Not applicable]
  • Eyes irrigated: [time / Not performed / Not applicable]
  • Wound dressing applied: [Yes / No / Not applicable]
  • Other first aid: [description / None]
• Environmental Actions: Area cleaned/decontaminated per protocol [yes / no / Not applicable]; Device disposed or secured [description]; Sharps container replaced if needed [yes / no / Not applicable]
• Notifications: (Record date/time and method for each.)
  • Supervisor notified: [date/time, method / Pending]
  • Safety officer/EHS notified: [date/time, method / Pending]
  • Infection prevention notified: [date/time, method / Not applicable / Pending]
  • Employee/Occupational health notified: [date/time, method / Pending]
  • After-hours protocol followed: [Yes / No / Not applicable], details: [brief description]

Source Information (Restricted Access)

(Store source-identifying information only in restricted fields per policy. Do not include detailed clinical results in this report.)

• Source Identified: [Yes / No / Unknown]
• If no, reason: [Unknown source / Found sharp / Identification not feasible / Other / Not applicable]
• Source Testing Status: (Operational status only.)
  • HIV: [Positive / Negative / Unknown / Declined / Pending / Not tested]
  • HBV (HBsAg): [Positive / Negative / Unknown / Declined / Pending / Not tested]
  • HCV: [Positive / Negative / Unknown / Declined / Pending / Not tested]

Medical Evaluation and Follow-up (Confidential)

(Track that required steps occurred. Detailed clinical findings belong in the confidential employee medical record, not this safety report.)

• Evaluation Service: [Employee health / ED / Urgent care / Designated clinic]
• Date/Time Evaluation Initiated: [date and time / Pending]
• Baseline Labs Collected: [Yes / No / Declined / Pending]
• HepB Vaccination Status Documented: [Yes / No / Unknown]
• Post-Exposure Prophylaxis (PEP):
  • PEP indicated per protocol: [Yes / No / Undetermined]
  • PEP offered: [Yes / No / Not applicable]
  • PEP started: [Yes / No]; Date/time started: [date and time / Not applicable]
  • If not started, reason: [Not indicated / Declined / Delayed access / Other / Not applicable]
• Counseling Provided: [Yes / No / Pending]
• Work Restrictions: [None / Restrictions in place] (If restricted, specify dates.)
• Follow-up Appointments Scheduled: [dates / Pending / Not applicable]
• Documentation Tracking:
  • Healthcare professional written opinion received: [Yes / No / Pending], date: [date / Pending]
  • Copy provided to employee: [Yes / No / Pending], date: [date / Pending]

Regulatory Recordkeeping

(For percutaneous contaminated sharps injuries, capture minimum data elements for the sharps injury log using the case/report number rather than names.)

• Sharps Injury Log Data:
  • Device type and brand: [details / Not applicable]
  • Department/work area: [area]
  • Brief explanation of how incident occurred: [concise description]
  • Case/report number: [identifier]
• OSHA 300/301 Determination: (If applicable.)
  • Work-related: [Yes / No / Undetermined]
  • Contaminated with another person's blood/OPIM: [Yes / No / Unknown]
  • Recordable: [Yes / No / Pending]
  • Privacy case: [Yes / No]
  • If OSHA recordkeeping handled by another entity: Forwarded to [entity name] on [date]

Investigation and Corrective Actions

• Initial Safety Review: [Brief summary of findings]; Additional investigation needed: [Yes / No]; Immediate corrective actions taken: [description / None]
• Contributing Factor Analysis: [Patient factors / Staff training or competency / Device or equipment factors / Work environment / Communication factors / Policy or procedure issues / PPE or barrier failure / Supervision or organizational factors] (Check applicable domains.)
  • Notes on contributing factors: [narrative analysis]
• Corrective Action Items: (For each action, document: action description, responsible person, due date, effectiveness measure, completion date and verification.)
  • [Action item details]

  If no corrective actions needed, rationale: [rationale]

Sign-offs and Closure

• Exposed Worker Acknowledgment: [Signature/Date / Not required per policy]
• Supervisor Review: [Name/Date / Pending]
• Safety/EHS Review: [Name/Date / Pending]
• Infection Prevention Review: [Name/Date / Not applicable / Pending]
• Employee Health Closure: [Name/Date / Not applicable / Pending]
• Attachments: [Witness statements / Photos or diagrams / Device packaging or lot information / Copies of forms routed to logs or workers' compensation / None] (Check all included. Ensure no patient identifiers in photos or diagrams.)

Updates and Addenda

(Use this section to add time-stamped updates as investigation proceeds. Do not overwrite prior entries.)

• Update: [Date/time], [Name, role]: [Summary of update]