Exposure to Blood/Body Fluids Page 2 of 7 Section II Percutaneous Injury – □ □ 1. *Was the needle or sharp object visibly contaminated with blood prior to exposure? Y N 2. Depth of the injury: (Check one) □ □ Superficial, surface scratch Deep puncture or wound □ □ Moderate, penetrated skin Unknown 3. What needle or sharp object caused the injury (Check one) □ □ □ Device (select one) Non-device sharp object (specify): ___________________ Unknown sharp object Hollow-bore needle □ □ □ Arterial blood collection device Biopsy needle Bone marrow needle □ □ Hypodermic needle, attached to Hypodermic needle, attached to IV □ Unattached hypodermic needle syringe tubing □ □ □ IV catheter central line IV catheter peripheral line Huber needle – – □ □ □ Prefilled cartridge syringe IV stylet Spinal or epidural needle □ □ □ Hemodialysis needle Dental aspirating syringe w/ needle Vacuum tube holder/needle □ Winged-steel (Butterfly™ type) □ □ Hollow-bore needle, type unknown Other hollow-bore needle needle Suture needle □ Suture needle Other solid sharps □ □ □ Bone cutter Bur Electrocautery device □ □ □ Elevator Explorer Extraction forceps □ □ □ File Lancet Microtome blade □ □ □ Pin Razor Retractor □ □ □ Rod (orthopedic) Scaler/curette Scalpel blade □ □ □ Scissors Tenaculum Trocar □ Wire Glass □ □ □ Capillary tube Blood collection tube Medication ampule/vial/bottle □ □ □ Pipette Slide Specimen/test/vacuum tube Plastic □ □ □ Capillary tube Blood collection tube Specimen/test/vacuum tube Non-sharp safety device □ □ □ Blood culture adapter Catheter securement device IV delivery system □ Other known device (specify): _________________________________ 4. Manufacturer and Model: _____________________________________
Exposure to Blood/Body Fluids Page 2 of 7 Section II – Percutaneous Injury 1. *Was the needle or sharp object visibly contaminated with blood prior to exposure? □ Y □ N 2. Depth of the injury: (Check one) □ Superficial, surface scratch □ Deep puncture or wound □ Moderate, penetrated skin □ Unknown 3. What needle or sharp object caused the injury (Check one) □ Device (select one) □ Non-device sharp object (specify): ___________________ □ Unknown sharp object Hollow-bore needle □ Arterial blood collection device □ Biopsy needle □ Bone marrow needle □ Hypodermic needle, attached to syringe □ Hypodermic needle, attached to IV tubing □ Unattached hypodermic needle □ IV catheter – central line □ IV catheter – peripheral line □ Huber needle □ Prefilled cartridge syringe □ IV stylet □ Spinal or epidural needle □ Hemodialysis needle □ Dental aspirating syringe w/ needle □ Vacuum tube holder/needle □ Winged-steel (Butterfly™ type) needle □ Hollow-bore needle, type unknown □ Other hollow-bore needle Suture needle □ Suture needle Other solid sharps □ Bone cutter □ Bur □ Electrocautery device □ Elevator □ Explorer □ Extraction forceps □ File □ Lancet □ Microtome blade □ Pin □ Razor □ Retractor □ Rod (orthopedic) □ Scaler/curette □ Scalpel blade □ Scissors □ Tenaculum □ Trocar □ Wire Glass □ Capillary tube □ Blood collection tube □ Medication ampule/vial/bottle □ Pipette □ Slide □ Specimen/test/vacuum tube Plastic □ Capillary tube □ Blood collection tube □ Specimen/test/vacuum tube Non-sharp safety device □ Blood culture adapter □ Catheter securement device □ IV delivery system □ Other known device (specify): _________________________________ 4. Manufacturer and Model: _____________________________________
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