New Jersey Department of Health

PEOSH Unit

EXPOSURE INCIDENT REPORT

(Routes and Circumstances of Exposure Incident)

(Please print)

Date Completed:
Employee’s Name:	SS#	_____ - ___ - _______
Home Phone:	Business Phone:
DOB:	Job Title:
Employee Vaccination Status:
Date of Exposure:	Time of Exposure:	AM PM
Location of Incident (Home, Street, Clinic, etc.). Be specific.
Nature of Incident (Auto Accident, Trauma, Medical Emergency). Be specific.
Describe what task(s) you were performing when the exposure occurred. Be specific.
Were you wearing personal protective equipment (PPE)? Yes No
If Yes, list:
Did PPE fail? Yes No
If Yes, explain how:
What body fluid(s) were you exposured to (blood or other potentially infectious material)? Be specific.
What parts of your body became exposed? Be specific.
Estimate the size of the area of your body that was exposed:
For now long?
Did a foreign body penetrate your body (needle, nail, auto part, dental wires, etc.)? Yes No
If Yes, what was the object?
Where did it penetrate your body?
Was any fluid injected into your body? Yes No
If yes, what fluid?	How much?
Did you receive medical attention? Yes No
If yes, where?
When?
By Whom?
Identification of source individual(s):
Name(s):
Did you treat the patient directly? Yes No
If yes, what treatment did you provide? Be specific:
Identification of source individual(s):

EXPOSURE INCIDENT REPORT

(Continued)

OCC-2

JAN 13	Page 2 of 2 Pages.

JAN 13	Page 1 of 2 Pages.

OCC-2, Exposure Incident Report

occ-2, Exposure Incident Report, OCC, peosh, Occupational

ewhite

2009-02-25

NJDOH