Needle Stick Exposure to Bodily Fluids Report Form

To submit this form, ensure it is fully filled out with all necessary details. Email it to the Director of Experiential Programs at [specific email], or you may choose to fax it to [specific fax number]. Additionally, physical copies can be submitted at [specific physical address]. Always check if online submission options are available.

Important deadlines for the submission of this form apply throughout the academic year. Check with the College of Pharmacy for specific dates related to exposure reporting and compliance requirements. Staying updated ensures prompt attention to incidents and health safety.

The purpose of the Needle Stick/Exposure to Bodily Fluids Report Form is to provide a formal mechanism for reporting incidents involving exposure to bodily fluids and needle sticks. This documentation is crucial for ensuring appropriate medical evaluation and follow-up procedures. Furthermore, it helps maintain health and safety standards within the College of Pharmacy by tracking such incidents.

• 1. Name of Person Injured: The name of the individual who experienced the exposure.
• 2. Student Identification Number (SID): An identifier for students involved.
• 3. Contact Phone Number: A phone number where the injured party can be reached.
• 4. Email Address: An email address for communication regarding the incident.
• 5. Today's Date: The date the form is being completed.
• 6. Date of Exposure: The date when the incident occurred.
• 7. Time of Exposure: The time when the exposure incident took place.
• 8. Brief Description of Exposure: A short narrative of how the exposure occurred.
• 9. Type(s) of Exposure or Injury: Checkbox options for various types of exposure.
• 10. Location Where Exposure or Injury Occurred: Specify where the incident took place.
• 11. Faculty/Staff/Student's Medical Provider: Information about the medical provider seen.
• 12. Date Provider Seen: Date when medical care was sought.
• 13. Patient/Source Name: Name of the patient or source involved.
• 14. Patient/Source Contact Information: Contact details for the patient or source.
• 15. Patient/Source Medical Provider: Medical provider linked to the patient or source.
• 16. Exposed or Injured Body Part(s): Checkbox options for body parts affected.
• 17. Date of Source Testing: Date when the patient or source was tested, if applicable.
• 18. Additional Information or Follow-Up: Field for any extra details or follow-up needs.

Failing to submit this form can result in delays in treatment or follow-up necessary after a needle stick or exposure incident. It is crucial to ensure timely reporting to prevent further health complications and to maintain institutional compliance.

• Delayed Medical Attention: Failure to report may impede timely medical evaluation for the injured individual.
• Inadequate Record Keeping: Lack of documentation could lead to incomplete records regarding safety incidents.
• Increased Health Risks: Not reporting incidents can increase the risk of complications or contagion.
• Compliance Issues: Delays in submission may result in non-compliance with safety regulations.
• Liability Concerns: Failure to properly document exposures could expose individuals and institutions to liability.

• 1. Following a Needle Stick Injury: Use this form to report any unintended puncture from needles.
• 2. Exposure to Blood or Bodily Fluids: Document incidents of contact with bodily fluids that may pose health risks.
• 3. Reporting at College Events: Utilize this form to report exposure incidents encountered during college-sponsored activities.
• 4. Internship and Volunteer Situations: Report exposures that occur in external internship or volunteer settings.
• 5. Health and Safety Compliance: Ensure reporting for compliance with health and safety protocols.