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PENN EXPOSURE CONTROL PLAN

APPENDIX E

University of Pennsylvania
Environmental Health and Radiation Safety

Post Exposure Evaluation Form
Needlestick and/or Other Sharp Object Injuries

Instructions: Complete this form to assist the University develop safer alternative work practices associated with needlesticks or other sharps injuries. Keep a copy of this form for your records. Return the completed form to EHRS, Suite 400, 3160 Chestnut Street/6287 or by FAX: 215-898-0140.

Employee Information

Name: ____________________ PENN ID #: ____________________
Position/Title: ____________________ School/Department:
 ____________________
Mailing Address: ____________________ Mail Code:
 ____________________
Telephone: ____________________ FAX: ____________________
E-mail: ____________________ Emergency Telephone: ____________________

 

Principal Investigator: ____________________ Telephone: ____________________

Injury Information:

Date and time of injury: ____________________ Body Part Injured (specific): ____________________

 

Location where injury occurred (specific laboratory room, clinical area, etc.): ____________________

What type of Personal Protective Equipment (PPE) were you wearing at the time of the exposure incident?

__ lab coat
__ gloves
__ safety glasses
__other, specify:____________

Procedure being performed at time of injury: ____________________________________________
Describe how the incident occurred:
 ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Device Information

Identify Sharp Involved (if known): ___________________________________________________
Type: _______________ Brand: ______________ Model: _______________

Did the sharps have engineered sharps injury protection?
__ Yes __ No __ Don’t know
Was the protective mechanism activated? __ Yes __ No __ Don’t know
When did the exposure incident occur? __ Before activation __ During activation__After Activation
Do you have an opinion that any other engineering control, administrative or work practice could have prevented the injury? __ Yes __ No __ Don’t know

Describe:
 _____________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

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