Hofstra University Physician Assistant Program Exposure Incident Investigation Form Date of Report: __________________________ Date of Incident _________________________
Time of Report: _____________ Time of Incident ____________
Name and Hofstra ID# of Student(s) involved in incident: Name of Preceptor/Instructor at time of incident: Location of potential exposure (classroom, Bioskills, or clinical clerkship): If clinical clerkship, include specific site, discipline, and rotation number (ex: Woodhull, IM, rotation #4) Exposure occurred as part of (check all that apply): ⃝ Supervised laboratory assignment ⃝ Patient care provided during clinical experience hours ⃝ Northwell Bioskills Lab ⃝ Other _______________________________________________________ Potentially Infectious Materials Involved: Type of body fluids, route, and source of exposure (ie. Needle stick, contact with open wound, etc) Circumstance (Task being performed, where, how, and severity of the exposure): How incident was caused? (Accident, equipment malfunction. if a device was being used include type and brand of device, whether or not it was a safety device, and when in the course of handling the device, the incident occurred): Personal protective equipment being used: (gloves, gown, etc.): Actions taken (decontamination, clean-up, immediate referral, reporting, etc.): Recommendations for avoiding repetition:
If at Northwell Bioskills Lab, a copy of the Anatomy Gifts Registry specimen data sheet is attached? YES NO Student has the Post-Exposure Evaluation and Follow-Up Checklist? circle one: YES NO Student Signature _____________________________________________________________________ Name and Title of Investigator (Academic Coordinator or Clinical Coordinator): Print and Sign _____________________________________________________________________
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