NOTE: You may need to double-tap on drop-down menus to make a selection when completing this form on a mobile device
INCIDENT INVOLVED (Work Comp., Vehicle, Gen. Liability, Property, Sharps, or Other):
Date and time employee started work on date of incident:
Last Date Employee worked:
Identify sharp involved (if known).
(EXAMPLE: "18ga. needle", "ABCMedical", “no stick syringe", "lot #101")