Public Employment Risk Reduction Program Division of Safety and Hygiene 13430 Yarmouth Drive Pickerington, Ohio 43147 614-644-2246 or 800-671-6858 Fax: 614-621-5754 State of Ohio Sharps Injury Form Needlestick Report Instructions: This form is to be used to report needlestick or sharps injuries by personnel in your organization responsible for reporting such incidents to the Public Employment Risk Reduction Program. It is preferred that the public employer submit all forms via the Internet. Public employer information 1) Employer: 3) Address: 4) City: 5) State: 2) Facility: Risk #: OH 6) ZIP code: 7) County: Address of reporter if different from facility where injury occurred (no P.O. boxes): 8) Date reported: By: Phone: Injury information 9) Date of injury: 13) Type of Sharp: Needle Blood gas syringe Insulin syringe with needle IV catheter- loose Needle connected to IV line Vacuum tube collection Needle factory-attached to syringe Other nonsuture needle Syringe- other Other syringe with needle Tuberculin syringe with needle 10) Time of injury: 11) Age of injured: 12) Sex of injured: Male Female Prefilled cartridge syringe (i.e. Tubex-type) Winged steel needle Surgical instrument (non glass) Lancet Glass Ampule Blood tube Other glass Other non-glass sharp Scalpel Staples Suture needle Trocar Wire Other tube Slide 15) Model number: 14) Brand (write brand name or "unknown"): 16) Job classification of injured person: Housekeeper/laundry Respiratory therapist 17) Employment status of injured person: Aide (e.g. CNA/HHA) LPN RN Maintenance Road crew Chiropractor MD/DO CRNA/NP Other PA EMT/paramedic Sewer & Sanitation Student Clinic Firefighter Surgery assistant/OR tech Phlebotomist/lab tech School personnel (not nurse) Employee Other Contractor/contract employee Volunteer EMS/fire/police 18) Type of location/facility/agency where sharps injury occurred: Home health Radiology Hospital Bloodbank/center/mobile Other School Correctional facility Laboratory (freestanding) Outpatient treatment (e.g. dialysis -infusion therapy) Residential facility (e.g. MHMR-shelter) 19) Work area where sharps injury occurred (select best choice): Critical care unit Dialysis room/center Home Pre-op or PACU Floor - not patient room Patient/resident room Infirmary Autopsy/pathology Emergency dept. Laboratory Procedure room L&D Blood bank/center/mobile Medical/outpatient clinic Roadside park Central sterile OR Seclusion room EMS/fire response Radiology Other Field (non EMS) Service/utility area (e.g. laundry) 20) Original intended use of sharp: Drilling Sewage treatment facility Contain specimen/pharmaceutical Finger stick/heel stick Wiring Other Cutting (surgery) Draw arterial sample Injection - IM Draw venous sample Injection - SC/ID Suturing - deep Electrocautery Heparin or saline flush Obtain body fluid/tissue sample Suturing - skin Unknown/NA Other injection/aspiration IV Start IV or set up heparin lock BWC-6611 SH-12 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 Injury information - continued 21) When did injury occur? Before After During ...the sharp was used for its intended purpose. 22) If the exposure occurred "during" or "after" the sharp was used, was it: Sharps Injury Form Because the injured was bumped during the procedure Because the item was placed in an inappropriate place (e.g. table/bed/trash) During OR procedure reaching for or passing instrument While the sharp was being placed in a container 23) Involved body part: Arm (but not hand) Face/head/neck While disassembling Other Torso (front or back) No Don't Know While recapping Hand Leg/foot Yes 24) Did the device being used have any engineered sharps injury protection? 25) Was the protective mechanism activated? 26) Was the injured person wearing gloves? Yes Yes No No Don't Know Don't Know Yes 27) Had the injured person completed a hepatitis B vaccination series? No Yes Don't Know No Don't Know Yes No Don't Know 28) Was there a sharps container readily available for disposal of the sharp? 29) Had the injured person received training on the exposure control plan in the 12 months prior to the incident? 30) Exposed employee: If sharp had no engineered sharps injury protection, do you have an opinion that such a mechanism could have prevented the injury? Yes No Explain: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ 31) Exposed employee: Do you have an opinion that any other engineering, administrative, or workpractice control could have prevented the injury? Yes No Explain: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ Public Employment Risk Reduction Program Division of Safety and Hygiene 13430 Yarmouth Drive Pickerington, Ohio 43147 614-644-2246 or 800-671-6858 Fax: 614-621-5754 State of Ohio Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com