Employee Report of Injury, Incident and Blood Borne Pathogen (Exposure)

Employee Report of Injury, Incident and Blood Borne Pathogen (Exposure)
Please complete all fields & include as much detailed information as possible.
The employee or supervisor will complete this form at the time of injury and will notify Human Resources IMMEDIATELY at:

(607) 353-7272 ext. 2300.

Please complete this form in its entirety and sign. Once you click Submit, the form will automatically route to Human Resources.
Name of Injured

First NameLast Name
DOB

MonthDayYear
Date
Gender
Personal Phone #
Format: (000) 000-0000.
Work # & Extension
Address

Physical Home Address: (Cannot be a PO Box)

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Job Title
Springbrook Affiliate
Work Location
Work Schedule: (Days and Times)
Date of Incident

MonthDayYear
Date
Time Punched In

Hour Minutes

AM/PM Option
Time of Incident

Hour Minutes

AM/PM Option
Date Reported to Supervisor

MonthDayYear
Date
If report is delayed, please give reason

0/50
Cause of Injury
Other: Please describe *SCIP-R - Please describe maneuver/technique implemented

0/50
Initials of Participant Involved
List All Injured Body Parts: (indicate left, right, top, bottom, upper, inner, etc.)
Nature of Injury: (indicate bite, scratch, cut, strain, sprain, head butt, etc.)
Were you exposed to pathogens? All human bites, scratches or incidents involving bodily fluids are at risk of exposure. The PPB Report must be completed for these injury types. If unsure, select yes.
Was medical treatment required?
If yes, where were you seen?
Name of Facility
Name of Provider
Was ambulance transportation necessary?
Did the employee miss scheduled work time from beyond date of injury?
Was this the result of unsafe facilities/environmental factors?
If yes, please describe
Where did injury/incident happen?
Specific Location
Room
Other
Was an object of materials involved?
If yes, please describe
Were you wearing Personal Protective Equipment (PPE)
If yes, please describe; If no, why not?
Please describe in detail the cause of what led up to injury/incident
Please describe in detail how Injury/incident happened and what employee was doing when injury/incident occurred
Was the employee doing something other than required duties?
If yes, please explain
Was this a motor vehicle accident?
If yes, please attach a copy of the police report. File Upload

Cancelof
Please provide vehicle make, model and plate number
Prevention

To be completed by supervisor
What should be done to prevent recurrence of this type of incident?
Was maintenance/facilities contacted?
Work Order #
Does this require additional follow up? If yes, who is assigned?
If yes, who is assigned?
Incident to be discussed at a staff meeting?
Date to be discussed?

MonthDayYear
Date
Incident Investigation Information
Does injury/incident require investigation?
If yes, who is assigned to the investigate?
Employee Name

First NameLast Name
Employee SIGNATURE

Clear
DATE

MonthDayYear
Date
Supervisor Name

First NameLast Name
PLEASE NOTE: Incomplete forms will be sent back to the signing supervisor for completion.
EMPLOYEE REPORT OF INJURY, INCIDENT & BLOOD BORNE PATHOGEN (EXPOSURE)
Blood Borne Pathogen Exposure Injury/Incident Supplemental Information:

ALL human bites, scratches or incidents involving bodily fluids are at risk of exposure. The BBP Report MUST be completed for these injury types.
Please specify the type of exposure: (Choose one)
What bodily fluids were you exposed to? (Choose all that apply)

Other
Did the bodily fluid: (Choose all that apply)

Other
How much bodily fluid came in contact (Provide approximation)

Other
What personal protective equipment was being used?

Other
* If none were used please explain why
Was a medical sharps device used?
Specify Device
Was it a "safety designed" device?
If yes, what failed to prevent injury?
Have you ever received HBV vaccine?
Specify Date Received

MonthDayYear
Date
Do you intend to seek medical treatment?
If no, why not
Advisement: All medical information regarding Springbrook employees is strictly confidential.

ALL human bites, scratches, or incidents involving bodily fluids are at risk of exposure and the BBP report MUST be completed. If you are involved in an injury which results in exposure to bodily fluids (blood, saliva, etc) you may elect to seek first aid and/or counsel from a medical provider, which would be covered by Worker's Compensation. If you are struck by a needle or other sharp or get other potentially infections materials in your eyes, nose, mouth, or broken skin, immediately flood the exposed area with water and clean any wounds.

By signing below you are acknowledging that you have been advised to seek medical care and are aware of the risks associated with exposure to bodily fluids.
Employee Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Employee Report of Injury, Incident and Blood Borne Pathogen (Exposure)

Please complete all fields & include as much detailed information as possible.

Prevention

Incident Investigation Information

EMPLOYEE REPORT OF INJURY, INCIDENT & BLOOD BORNE PATHOGEN (EXPOSURE)