Exposure to Blood/Body Fluids Page 5 of 7 Section III Mucous Membrane and/or Skin Exposure – 1. Estimate the amount of blood/body fluid exposure: (Check one) □ □ Small (<1 tsp or 5cc) Large (> ¼ cup or 50cc) □ □ Moderate (>1 tsp and up to ¼ cup, or 6-50 cc) Unknown 2. Activity/event when exposure occurred: (Check one) □ Airway manipulation (e.g., suctioning airway, □ Patient spit/coughed/vomited inducing sputum) □ □ Bleeding vessel Phlebotomy □ Surgical procedure (e.g., all surgical procedures □ Changing dressing/wound care including C-section) □ Tube placement/removal/manipulation (e.g., chest, □ Cleaning/transporting contaminated equipment endotracheal, NG, rectal, urine catheter) □ □ Endoscopic procedures Vaginal delivery □ □ IV or arterial line insertion/removal/manipulation Other (specify): _______________________________ □ □ Irrigation procedures Unknown □ Manipulating blood tube/bottle/specimen container 3. Barriers used by the worker at the time of exposure: (Check all that apply) □ □ Face shield Mask/respirator □ □ Gloves Other (specify): _______________________________ □ □ Goggles No barriers □ Gown Section IV Bite – 1. Wound description: (Check one) □ □ No spontaneous bleeding Tissue avulsed □ □ Spontaneous bleeding Unknown 2. Activity/event when exposure occurred: (Check one) □ □ During dental procedure Assault by patient □ □ During oral examination Other (specify): _______________________________ □ □ Providing oral hygiene Unknown □ Providing non-oral care to patient
Exposure to Blood/Body Fluids Page 5 of 7 Section III – Mucous Membrane and/or Skin Exposure 1. Estimate the amount of blood/body fluid exposure: (Check one) □ Small (<1 tsp or 5cc) □ Large (> ¼ cup or 50cc) □ Moderate (>1 tsp and up to ¼ cup, or 6-50 cc) □ Unknown 2. Activity/event when exposure occurred: (Check one) □ Airway manipulation (e.g., suctioning airway, inducing sputum) □ Patient spit/coughed/vomited □ Bleeding vessel □ Phlebotomy □ Changing dressing/wound care □ Surgical procedure (e.g., all surgical procedures including C-section) □ Cleaning/transporting contaminated equipment □ Tube placement/removal/manipulation (e.g., chest, endotracheal, NG, rectal, urine catheter) □ Endoscopic procedures □ Vaginal delivery □ IV or arterial line insertion/removal/manipulation □ Other (specify): _______________________________ □ Irrigation procedures □ Unknown □ Manipulating blood tube/bottle/specimen container 3. Barriers used by the worker at the time of exposure: (Check all that apply) □ Face shield □ Mask/respirator □ Gloves □ Other (specify): _______________________________ □ Goggles □ No barriers □ Gown Section IV – Bite 1. Wound description: (Check one) □ No spontaneous bleeding □ Tissue avulsed □ Spontaneous bleeding □ Unknown 2. Activity/event when exposure occurred: (Check one) □ During dental procedure □ Assault by patient □ During oral examination □ Other (specify): _______________________________ □ Providing oral hygiene □ Unknown □ Providing non-oral care to patient
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