Bloodborne Exposure Incident Report Form

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Institution _______
ID _______
Bloodborne Exposure Incident Report
-Questionnaire and Report-
1.
Identification Number: ______________________________
2.
Date of report: ______________________________
3.
Date of exposure occurrence: ______________________________
4.
Time of exposure __________am / pm
5.
How many uninterrupted hours had you been working when this exposure occurred?: ________
6.
Working Area:
A.__ Dental Operatory
B.__ Dental Laboratory
C.__ Sterilization Area
D.__ Emergency Clinic
E.__ Oral Surgery Clinic
F.__ Pediatric Clinic
G.__ Post-Graduate Clinics (specify________________)
H.__ Operating Room
I.__ Research Laboratory
J.__ Other (specify________________)
7.
Professional Category:
A.__ Dental Faculty
Specialty ________________
B.__ Dental Assistant
C.__ Dental Hygienist
D.__ Dental Resident (year of residency 1,2,3,4,5)
Specialty ________________
E.__ Dental Student (academic year 1,2,3,4)
F.__ Dental Hygiene Student (academic year 1,2,3,4)
G.__ Dental Assistant Student (academic year 1,2)
H.__ Sterilization Technician
I.__ Laboratory Technician
J.__ Staff
K.__ Other (specify________________)
8.
Have you had a previous exposure incident?: ___ Yes ___ No
9a.
If the answer to Question #9 is ‘Yes’, How many times have you been exposed?: ___
9b.
Was the previous exposure documented?: ___ Yes ___ No
EXPOSURE REPORT TEMPLATE
May 2000
1
Institution _______
ID _______
Bloodborne Exposure Incident Report
-Questionnaire and Report-
1.
Identification Number: ______________________________
2.
Date of report: ______________________________
3.
Date of exposure occurrence: ______________________________
4.
Time of exposure __________am / pm
5.
How many uninterrupted hours had you been working when this exposure occurred?: ________
6.
Working Area:
A.__ Dental Operatory
B.__ Dental Laboratory
C.__ Sterilization Area
D.__ Emergency Clinic
E.__ Oral Surgery Clinic
F.__ Pediatric Clinic
G.__ Post-Graduate Clinics (specify________________)
H.__ Operating Room
I.__ Research Laboratory
J.__ Other (specify________________)
7.
Professional Category:
A.__ Dental Faculty
Specialty ________________
B.__ Dental Assistant
C.__ Dental Hygienist
D.__ Dental Resident (year of residency 1,2,3,4,5)
Specialty ________________
E.__ Dental Student (academic year 1,2,3,4)
F.__ Dental Hygiene Student (academic year 1,2,3,4)
G.__ Dental Assistant Student (academic year 1,2)
H.__ Sterilization Technician
I.__ Laboratory Technician
J.__ Staff
K.__ Other (specify________________)
8.
Have you had a previous exposure incident?: ___ Yes ___ No
9a.
If the answer to Question #9 is ‘Yes’, How many times have you been exposed?: ___
9b.
Was the previous exposure documented?: ___ Yes ___ No
EXPOSURE REPORT TEMPLATE
May 2000
1
Institution _______
ID _______
-Information About This Exposure-
10.
Did the exposure involve:
A.__ Blood
B.__ Saliva only
C.__ Blood and Saliva
D.__ Unknown
E.__ Other (specify________________)
11.
Are you:
A.__ Right-Handed
B.__ Left-Handed
12.
Were you:
A.__ Self-Exposed
B.__ Exposed by Another Person
If B, please explain in 15, below.
13.
Type of exposure:
A.__ Needle Injury
1.__Syringe Needle
Gauge ________________
2.__Suture Needle
B.__ Cut, Puncture, or Scrape by Other Instruments
1.__Bur
2.__Scalpel Blade
3.__Endodontic File
4.__Wire (specify________________)
5.__Hand Instrument (specify________________)
6.__Other (specify________________)
C.__ Splash (check all that apply)
1.__Eyes
2.__Mouth
3.__Nose
4.__To Existing Wound
5.__To Intact Skin
6.__To Non-Intact Skin (specify________________)
7.__Other (specify________________)
D.__ Bitten by Patient
E.__ Other (specify________________)
14.
If you checked 13.A. or B., please specify the brand of instrument involved in the exposure:
_______________________________________
EXPOSURE REPORT TEMPLATE
May 2000
2
Institution _______
ID _______
15.
Describe the circumstances under which this exposure occurred. Be as specific as possible.
16.
Description of procedure in progress when exposure occurred:
A.__ Hygiene (e.g., prophylaxis, root planing, curettage)
B.__ Restorative (e.g., amalgam, composite, crown)
C.__ Root Canal
D.__ Periodontal Surgery
E.__ Oral Surgery
1.__Simple extraction
2.__Surgical extraction
3.__Fracture reduction
4.__Other (specify________________)
F.__ Other (specify________________)
17.
Where did the exposure occur?:
A.__ Inside patient’s mouth
B.__ Outside patient’s mouth
C.__ Unknown
18. When did the exposure occur?:
A.__ Before use of the item
B.__ During use of the item
C.__ After use but before disposal
D.__ During or after disposal
E.__ During cleaning
F.__ Unknown
EXPOSURE REPORT TEMPLATE
May 2000
3
Institution _______
ID _______
19.
How did the exposure occur?:
A.__ While manipulating patient or instrument
1.__Patient moved and jostled instrument or sharp item
2.__While inserting needle in patient
3.__While withdrawing needle from patient
4.__Other (specify_______________________)
B.__ During surgical procedures
1.__Suturing
2.__Incising
3.__Other (specify_______________________)
C.__ Handling equipment
1.__Passing or transferring equipment
2.__Recapping (missed or pierced cap)
3.__Removing needle from syringe
4.__Assembling or disassembling equipment
5.__During cleanup
6.__Other (specify_______________________)
D.__ Collision or contact with sharp object
E.__ Disposal-related (e.g., injured by device being disposed of, sharp already in
container, sharp protruding from container, overfilled container)
F.__ Other (specify________________)
20.
Personal protective equipment being utilized at time of accident:
(check all that apply)
A.__ Single Gloves
B.__ Double Gloves
C.__ Utility Gloves
D.__ Mask
E.__ Mask w/ Shield
F.__ Goggles
G.__ Non-safety (prescription) glasses
H.__ Glasses w/ side shields
I.__ Face Shield
J.__ Gown
K.__ Other (specify________________)
21. Was an engineering control or a device equipped with an engineering control in use during this exposure
incident?:
___ Yes ___ No
22. If yes, what kind?
A.__ Instrument cassette
B.__ Needle recapper
C.__ Safety-enhanced device (e.g., safety needle)
EXPOSURE REPORT TEMPLATE
May 2000
4
Institution _______
ID _______
23. Circumstances contributing to this exposure:
(Choose all that apply. Rank in order of importance [1=most important].)
A.__ Unfamiliar Procedure
B.__ Concern about patient’s infection/illness
C.__ Difficulty with procedure
D.__ Rushing Procedure
E.__ Pressure from environment
F.__ Location of Instruments
G.__ Location of equipment (e.g. handpieces, mobile cart)
H.__ Faulty or malfunctioning equipment
I.__ Being distracted
J.__ Poor visibility
K.__ Poor positioning
L.__ Not following procedure steps correctly
M.__ Other (specify____________________________)
24.
Was the instrument involved in this exposure reused on the patient after the incident without recleaning?
___Yes ___ No ___ Unknown
25.
What might have prevented this exposure?:
A.__ More instruction
B.__ More assistance
C.__ More time
D.__ Less pressure
E.__ Having more experience
F.__ Better personal protective equipment (specify______________________)
G.__ Safer devices (specify______________________)
H.__ Improved engineering controls (specify______________________)
I.__ Better location of instruments
J.__ Better location of equipment
K.__ Better visibility
L.__ Better positioning
M.__ Other (Be as specific as possible)
(specify ___________________________________________________)
EXPOSURE REPORT TEMPLATE
May 2000
5

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