Quickly Report Needlestick & Bloodborne Pathogen Exposures

Let hospital staff report needlestick and bloodborne pathogen exposures in minutes, capturing details for post-exposure follow-up and sharps injury logs.

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Hospital Staff Needlestick & Bloodborne Pathogen Exposure Incident Report Form

Employee Name

· · ·

Employee ID / Badge Number

· · ·

Job Category

Submit

This Hospital Staff Needlestick and Bloodborne Pathogen Exposure Incident Report Form gives healthcare workers a clear, structured way to document sharps injuries and exposures to blood or other potentially infectious materials. It captures employee information, the date, time, and department where the exposure occurred, the type of exposure, body fluids involved, the device or object involved and whether it had a safety-engineered feature, the personal protective equipment worn, and a step-by-step account of how the incident happened. Dedicated sections record the source patient's MRN or identifier and known infection status, along with the immediate actions taken.

The template is built for hospitals, clinics, surgical centers, long-term care facilities, and laboratories, where nurses, physicians, phlebotomists, environmental services staff, and other frontline workers are at risk of occupational exposure. Employee health, infection prevention, and occupational safety teams can use each submission to coordinate post-exposure evaluation, testing, and treatment without chasing down missing details.

Because post-exposure care is time-sensitive, a fast and complete report matters. A digital form lets staff report incidents right away from a phone, tablet, or workstation. It also helps ensure details such as device type, brand, and work area are captured consistently for your sharps injury log, and gives your safety team the data needed to spot trends and evaluate safer devices. Customize the fields, add your facility's branding, and route submissions to the right people so every exposure is documented and followed up promptly.

3 Pages

20 Questions

~7min To complete

Free No credit card needed

Field types Dropdown ×5 Multiple Choice ×4 Full Name ×2 Short Text ×2 Long Text ×2 Phone Date Time Picker termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Employee Information 5 questions

Employee Information

1 Employee Name * Full Name

2 Employee ID / Badge Number * Short Text

3 Job Category * Dropdown

4 Best Contact Phone Number * Phone

5 Supervisor Name * Full Name

Page 2 Exposure Incident Details 9 questions

Exposure Incident Details

1 Date of Exposure * Date

2 Time of Exposure * Time Picker

3 Department / Work Area Where Exposure Occurred * Dropdown

4 Type of Exposure * Dropdown

5 Body Fluid(s) Involved * Multiple Choice

6 Device or Object Involved * Dropdown

7 Did the Device Have a Safety-Engineered Feature? * Dropdown

8 Personal Protective Equipment (PPE) Worn * Multiple Choice

9 Describe How the Exposure Occurred (procedure being performed, sequence of events, and device brand if known) * Long Text

Page 3 Source Patient, Follow-Up & Certification 6 questions

Source Patient, Follow-Up & Certification

1 Source Patient MRN or Identifier (if known) Short Text

2 Source Patient's Known Infection Status * Multiple Choice

3 Immediate Actions Taken * Multiple Choice

4 In Your Opinion, How Could This Exposure Have Been Prevented? Long Text

5 I certify that the information in this report is accurate and complete to the best of my knowledge. I understand it will be kept confidential and used only for post-exposure medical follow-up, OSHA recordkeeping, and infection prevention, and that I have been advised to seek immediate medical evaluation. * termsandconditions

6 Employee Signature * Signature

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.