Frostburg State University DPAM Notice of Incident Report Form
Report Date________________
Last Name: _______________________ First Name___________________________________
Address______________________________________________________________________
Supervisor/Clinical Instructor: ___________________________________________________
Date of incident: _______________________ Time of incident: _____________________
Facility and specific location of incident: ____________________________________________
Job description (description of general duties): _______________________________________
Potentially infectious material involved (e.g. blood etc.): ______________________________
Source of potentially infectious material (e.g. needle-stick, cut, bite etc.) ________________
Circumstances surrounding exposure (e.g. work being performed) ________________________ ______________________________________________________________________________
Route of exposure (e.g. stick, splash, etc.)____________________________________________ ______________________________________________________________________________
How exposure occurred (e.g. equipment malfunction) _________________________________ ______________________________________________________________________________
Personal protection equipment worn at time of incident ________________________________ ______________________________________________________________________________
Actions taken at time of incident (e.g. soap/water clean-up, reporting etc.) _________________ ______________________________________________________________________________ ______________________________________________________________________________
Recommendations for avoiding repetition: __________________________________________