Report • CampusOptics

This form is for reporting STUDENT bloodborne pathogen exposure and near-miss incidents. Employees should report exposure incidents through the C-1 process, not this reporting form.

For student incidents occurring off campus at a clinical site, search "off campus" under Location Name.

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Exact Location

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STUDENT INFORMATION

Student Name

NSHE ID Number

Phone

Email Address

Academic Program where enrolled

Clinical Coordinator/Responsible Faculty Name

INCIDENT DETAILS

Date of Incident

Time of Incident

Facility & Department where incident occurred

Type of Incident (check one)

Did the incident/exposure result in any of the following? (check all that apply)

Percutaneous exposure (break in skin that caused bleeding)

Mucous membrane contact (eyes, nose, mouth)

Abraded skin, chapped skin, dermatitis

Other

Did the Student seek post-exposure medical evaluation and care?

STUDENT STATEMENT

Describe precisely how the incident occurred.

If applicable, describe the medical device type, brand, etc. (e.g., 25-gauge BD Vacutainer blood collection needle)

Describe the PPE and/or controls in use at the time of the incident.

Who was notified at the time of the incident?

Describe what was done immediately after the incident.

Describe how this incident could have been prevented.

Add Supporting Documents

Add files to upload as supporting documentation along with your incident.