Nexus

Formed AI

NOTE: You may need to double-tap on drop-down menus to make a selection when completing this form on a mobile device

Department Name *

Date of incident *

Time of incident *

Name Of

Employee

Other Party Involved

Name(s) *

Title

Gender

Date Of Birth

Clock No. Or Last 4 Of SSN

Date Notified Employer

Employment Status

INCIDENT INVOLVED (Work Comp., Vehicle, Gen. Liability, Property, Sharps, or Other):

Work Comp

Vehicle

Gen. Liability

Property

Exposure

Sharps

Other

Incident Location *

Photos Available?

Yes

Type Of Damage And/or Body Parts Affected (such As Dented Fender, Sprained Ankle, Cut Finger, Became Dizzy, Etc.) *

Describe How Incident Occurred (what Happened, Etc.) *

(No insurance claim to be filed at this time)

Action(s) Taken (list Where Treatment Received And/or Type Of Action Taken)

Witness To Occurrence

Phone

If Workers Comp Related

Company Nurse Notified?

Employee DOB

Employee Phone

Employee Mailing Address

Did Employee Return To Work?

Date and time employee started work on date of incident:

Date

Time

Last Date Employee worked:

Date

If Vehicle Related

City Vehicle Number

VIN (last 4)

Police Report Filed?

Seat Belt In Use?

City Vehicle ( Year And Make/Model)

Cell Phone In Use At Time Of Incident?

If Yes

If Exposure Related

Description Of The Exposure Incident (include PPE In Use At Time Of Exposure):

Did The Exposure Incident Occur?

Before activation

During activation

After activation

Exposure Incident Employee Opinion: Do You Have An Opinion That Any Other Engineering, Administrative Or Work Practice Control Could Have Prevented The Incident?

Yes

Explain

Did Employee Seek Medical Attention?

Call Co. Nurse?

Yes

Health Care Facility

Facility Phone No.:

If Sharps Related

Procedure Being Performed At Time Of Incident: (Check All That Apply)

Draw venous blood

Heparin/saline flush

Draw arterial blood

Start IV/set up heparin lock

Handle medical waste

Provide First Aid/CPR

Cutting

Suturing

Injection through skin

Other

Incident Occurred: (Check All That Apply)

During use of sharp

Disassembling

Between steps of a multistep procedure

After use and before disposal of sharp

While putting sharp into disposal container

Sharp left in inappropriate place (table, bed, trash, etc.)

Other

Body Part: (Check All That Apply)

Finger

Face/head

Hand

Torso

Arm

Leg

Other

Identify sharp involved (if known).

(EXAMPLE: "18ga. needle", "ABCMedical", “no stick syringe", "lot #101")

Type

Brand:

Model:

Lot No.:

Did The Device Being Used Have Engineered Sharps Injury Protection?

Yes

Don't know

Was The Protective Mechanism Activated?

Yes, Fully

Yes, Partially

Sharps Incident Employee Opinion: If Sharp Had No Engineered Sharps Injury Protection, Do You Have An Opinion That Such A Mechanism Could Have Prevented The Incident?

Yes

Explain

Did Employee Seek Medical Attention?

Call Co. Nurse?

Yes

Health Care Facility

Facility Phone No.:

Name Of Person Filing Report

Date

Department Manager / Supervisor Name

Department Manager / Supervisor Email

Incident Report

Attachments