Incident 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* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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EXPOSED INDIVIDUAL INFORMATION

Name of Exposed Individual* Required

Address* Required

Phone* Required

UNT Department | Unit* Required

EXPOSURE INCIDENT

Occurred At* Required

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

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:* Required

RELEVANT MEDICAL INFORMATION

Hepatitis B vaccinations received* Required

Hepatitis B titer (HBsAb) results* Required

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.)* Required

Add Supporting Documents

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