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DocuSign Envelope ID:79C5D167-B6CA-4E59-B4AC-AA38CC1 B20BD <br /> Orange County Emergency Services <br /> Exposure Control Policy <br /> Report of Occupational Exposure <br /> Employee Name <br /> Division / Department <br /> Job Title Supervisor <br /> Date of Exposure Time of Exposure am / pm <br /> Type of Exposure: Needlestick Splash Other <br /> (explain) <br /> Type of Fluid Amount of Fluid <br /> Severity (depth of injury) <br /> Part of Body <br /> Exposed <br /> Location of Exposure (address of <br /> incident) <br /> Please describe how/why the exposure occurred. Include job duties being performed at time <br /> of exposure, extent and duration of exposure: <br /> Personal Protective Equipment Used: Gloves Face Mask Face / Eye Shield Goggles <br /> Gown Other (explain) <br /> Date and Time Reported to Supervisor / / am / pm <br /> Time Needle Stick Hotline Called am / pm <br /> Date and Time Reported to EC Officer / / am / pm <br /> Preliminary Instructions to the Employee <br /> Date Employee Seen at UNC <br /> By <br /> Report Received By EC Officer <br /> Revised July,2018 1 <br />