Exposure Incident Investigation Form

Hofstra University Physician Assistant Program Exposure Incident Investigation Form

Date of Report: __________________________ Time of Report: _____________ Date of Incident _________________________ Time of Incident ____________

Name and Hofstra ID# of Student(s) involved in incident:

Name of Preceptor/Instructor at time of incident:

Location of potential exposure (classroom, bioskills, or clinical clerkship):

If clinical clerkship, include specific site, discipline, and rotation number (ex: Woodhull, IM, rotation #4)

Exposure occurred as part of (check all that apply):

Supervised laboratory assignment Patient care provided during clinical experience hours Northwell Bioskills Lab Other _______________________________________________________

Potentially Infectious Materials Involved: Type of body fluids, route, and source of exposure (ie. Needle stick, contact with open wound, etc)

Circumstance (Task being performed, where, how, and severity of the exposure):

How incident was caused? (Accident, equipment malfunction. if a device was being used include type and brand of device, whether or not it was a safety device, and when in the course of handling the device the incident occurred):

Personal protective equipment being used: (gloves, gown, etc.):

Actions taken (decontamination, clean-up, immediate referral, reporting, etc.):

Recommendations for avoiding repetition:

If at Northwell Bioskills Lab, a copy of the Anatomy Gifts Registry specimen data sheet is attached? YES NO Student has the Post-Exposure Evaluation and Follow-Up Checklist? circle one: YES NO

Student Signature _____________________________________________________________________