Exposure Incident Forms

In many healthcare settings, it is possible that an employee is exposed to bloodborne pathogens (BBP).  In this case, the following two forms need to be filled to document the event.

There are two forms. These are designed to document:

  • The incident and collect necessary facts

  • What the medical professional seen by the employee did to remedy or mitigate the risks of the exposure.

The Exposure Determination form

This form must be filled by the person involved in the incident to document the facts of the exposure incident.  In the event of an incident, download this form and fill in the details of the incident.   It is important to do this at the time the event occurs.


Use the link below to download the form PDF:


The Physician Exposure Determination form 

This is the form that is filled by the physician you see at the emergency or urgent care facility after a needlestick injury.

Use the link below to download the form PDF: