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: __________________________________________