Office of Human Resources, EAR001, rev. 10/29/2020
Employee Accident Report, Page 4 of 4
ALL parts of this form MUST be completed with as much detail as possible.
This form must be submitted directly to Integrated Absence Management and Vocational Services (not to supervisor).
SECTION 1: EMPLOYEE INFORMATION
Employee’s Full Name: First M.I. Last OSU Employee ID#
Occupation Phone Number (for reporting lab results) Date of Hire
Date of exposure:
Time of exposure: Number of hours on duty: Pregnant: Yes No
SECTION 2: BBFE INFORMATION
Specific location of exposure (room use and building): ______________________________________________________________________________________________
Location type (patient room, laboratory, bathroom): ________________________________________________________________________________________________
Cause of the exposure (splash, needlestick, bite): __________________________________________________________________________________________________
Detailed account of the event (be as specific and detailed as possible): _________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
In your opinion, what could have prevented this BBFE? (be specific): ___________________________________________________________________________________
SECTION 3: NEEDLESTICKS/SHARPS INJURIES
Was the sharp item: Contaminated Uncontaminated Unknown
Source of contamination (blood; other–please specify):
___________________________________________________________________________________________
Depth of injury: No visible wound Superficial (surface scratch) Moderate (penetrated skin) Deep puncture or wound
Was the sharp being held? Yes No
If not, was the sharp: Hands too close to someone else handling sharp Being passed by someone else
Dropped by someone else Set aside for future use Inappropriately discarded or left there by someone else
Type of sharp: Needle for blood draw Central line placement Insulin pen
Push button butterfly Lidocaine Novo Nordisk Innolet (Reg or NPH)
Multi sampling needle Introducer Novo Nordisk Flex Pen
Slide safety butterfly Scalpel (Novolog Aspart or 70/30)
ABG needle Other Solostar (Lantus)
Syringe to draw cord blood Lilly (Humalog)
Other
Peripheral IV Huber needle Suture needle
Angioset (butterfly) Safety
Angiocath (straight) Non-safety
Needle for injection EMG/SSEP needle Surgical instrument ____________________________
If administering lidocaine, was needle: Being reused Set aside for reuse Stuck self while administering Recapping
If scalpel, was it a safety (retractable) scalpel?
___________________________________________________________________________________________________
Do you feel the device was defective?* ________________________________________________________________________________________________________
*If YES, please save device for University Health Services if possible.
SECTION 4: SPLASHES
Was this exposure related to a splash? _________________________________________________________________________________________________________
Fluid Involved: Blood Urine Stool
Vomitus Sweat, tears Saliva, sputum
Vent condensation CSF, synovial, pleural, peritoneal, pericardial, or amniotic fluid
If urine, sweat, vomitus, stool, saliva, sputum, or vent condensation, was fluid visibly bloody?
______________________________________________________________
What type of personal protective equipment (PPE) was worn during exposure? _________________________________________________________________________
Gloves Gown Goggles Mask with face shield Mask
If splashed, fluid came in contact with: Intact skin Non-intact skin Eyes
Nose Mouth Other
Did someone else inadvertently splash you?
____________________________________________________________________________________________________
If this BBFE was caused by a splash, list barrier protections that could have prevented it: _________________________________________________________________
Blood/Body Fluid Exposure Addendum