Management of Needlestick & Contamination Injuries - Royal ...

Appendix ANeedlestick/Sharps Incident Risk Assessment FormSurname: Forename: DoB:Date of Incident:Date of Reporting/Assessment:Time of Incident:Time of Reporting/Assessment:Place of Assessment:Department where Incident occurred:Directorate:Staff Member Hep B Status:Staff Member Job Title:Where did the incident occur?Describe the circumstances leading to the injury:Were First aid procedures followed?Was Accident Form completed?Was the donor source identifiable?Donor Source Details (affix label if applicable):Donor Source Name:DoB:Is Donor High Risk?Yes/NoAddress/Ward:Blood taken from Donor Source date:Evidence of /risk factors present by BBVResult of blood test by BBVHepatitis B AntigensDate:Hepatitis C AntibodiesDate:HIV AntibodiesDate:Needlestick/Sharps Incident Risk Assessment Form