BBP-1
BBP-1
EXPOSURE INCIDENT REPORT FORM
Employee Name
Employee Name
*
First
Last
UIN#:
*
Email
*
Department:
*
Date
Date
*
/
MM
/
DD
YYYY
Supervisor Name:
*
Description of Incident (be specific and include date, approximate time and place).
*
Immediate Actions Taken:
*
Source of Blood or OPIMs (include name of source individual, if known:
*
Personal Protective Equipment (PPE) worn:
*
Hepatitis B Vaccination Status (declination form offered through training & OccHealth):
*
Hepatitis B Vaccination Status (declination form offered through training & OccHealth):
Decline vaccine
Complete
1st shot
2nd shot
Employee Signature:
*
Date
Date
*
/
MM
/
DD
YYYY