Exposed Employee:
*
First Name
Last Name
Title:
*
Employee Email:
*
example@tmcc.edu
Date of Incident:
*
-
-
2 digit month, 2 digit day, 4 digit year
Time of Incident:
*
Hour Minutes
AM
PM
AM/PM Option
Location of Incident:
*
Job activity being performed when the incident occurred:
*
Potentially infectious materials that were involved (type):
*
Source:
*
Type of Exposure:
*
Needle
Ingestion
Open wound
Exposure to eyes/nose/other mucous membrane
Other
Describe Cause of Incident:
*
List Personal Protective Equipment that was being used:
*
List actions taken (decontamination, clean-up, reporting etc.):
*
Source person (if known):
*
Consented to testing?
*
Yes
No
Explain reason for denying testing:
*
Recommendations for avoiding future exposure incidents:
*
Please verify that you are human:
*
Sender Name:
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Should be Empty: