department of athletics policies & procedures - UNC Wilmington ...

FORM E:
THE UNIVERSITY OF NORTH CAROLINA WILMINGTON
DEPARTMENT OF ATHLETIC TRAINING
EXPOSURE INCIDENT FORM
Name: _________________________
Title: ____________________________
Date of Exposure: __________ Time: __________ Location: ________________
Type of Incident (circle): Exposure Only Exposure with Injury
□ If Exposure Only Incident, the HR BBP Incident Report been submitted (please
check).
Date and Time Submitted: ____________
Description of Incident:
Immediate Medical Care Received:
Follow-up Plan:
Please check one:
□ I have chosen to seek medical treatment presently and have been referred to the
Athletics Human Resources Representative.
□ I have chosen to decline medical treatment at the present time and have been referred to
the Athletics Human Resource Representative. However, I recognize that I reserve the
right to seek medical treatment now or in the future if I so desire.
________________________________________
Signature of Exposed Individual
_______________
Date
171