Download the OSHA manual - Wisconsin Dental Association

OCCUPATIONAL EXPOSURE INCIDENT REPORTFor use in this dental office/practice/facilityA SIGNIFICANT EXPOSURE OCCURS:1) Following percutaneous exposure (i.e., penetration of dental health care worker’s skin by a needle, a scalpelblade or other sharp object contaminated with a patient’s blood or other potentially infectious materials).2) Following contact between dental health care worker’s oral or nasal mucous membrane, cornea ornon-intact skin and patient blood, saliva or other potentially infectious materials (i.e., a splash ofpatient blood, saliva or other potentially infectious materials into the mouth, nose or eye of the dentalhealth care worker or direct contact of patient blood saliva or other potentially infectious material withan abrasion, cut or other opening in the skin of the dental health care worker).EMPLOYEE INFORMATIONExposed employee’s name:Phone:Position:FORM3Date of exposure:Date of HBV Vaccination:Date of Anti HBs test:FORUSE INOFFICEDate of last tetanus toxoid Vaccination:INCIDENT DESCRIPTION: (What occurred and where did it happen? Describe theexposure and whether this is a percutaneous, mucous membrane or corneal exposureas described above. What body part was affected?)Source patient antibody status (if known):SOURCE PATIENT INFORMATIONSource Patient HBsAg status: Positive NegativeHIV antibody status: Positive NegativeSource Patient HCV antibody status: Positive NegativeI, ____________________________ understand the significance of my exposure, as described above,I have been offered medical evaluation and treatment for the exposure but have decided, for personalreasons, not to have any such treatment.(Employer’s signature)(Employee’s signature)This document is CONFIDENTIAL and must be maintained by the employer for the length of employment plus 30 years.OSHA EXPOSURE CONTROL PLAN…a member benefit from the WDA 28