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Revised -XO\, 2011 <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 />Orange County Emergency Services <br />Exposure Control Policy <br />Report of Occupational Exposure <br />DocuSign Envelope ID: 79C5D167-B6CA-4E59-B4AC-AA38CC1B20BD