Report • CampusOptics

This information must be provided to the evaluating healthcare professional as soon as possible. Once the form is submitted, you will be able to print a copy of your submission and provide to your health care provider, as needed.

Applicable regulatory references required to be provided to the healthcare professional:

The US Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard
The Texas Department of State Health Services (DSHS) bloodborne pathogen control standard

Note: If this is a workers compensation claim, contact your supervisor within 24 hours to complete additional paperwork.

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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EXPOSED INDIVIDUAL INFORMATION

Name of Exposed Individual

Address

Phone

UNT Department | Unit

EXPOSURE INCIDENT

Occurred At

Description of individual’s duties as they relate to the exposure incident:

Description of the incident which exposed an employee or student to blood or other potentially infectious materials; including the route of exposure and the circumstances in which the incident occurred:

RELEVANT MEDICAL INFORMATION

Hepatitis B vaccinations received

Hepatitis B titer (HBsAb) results

HIV infection status

Hepatitis C infection status

Other relevant medical information for exposed individual: (forward exposed individual’s relevant medical records, including vaccination records, to evaluating health care professional as soon as possible.)

Add Supporting Documents

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