EXPOSURE INCIDENT EVALUATION FORM Date of Incident:____________   Time of Incident:_______________ Location: Employee(s) Exposed: Potentially Infectious Materials Involved: Type _______________________________ Source ____________________ _______________________________________________________________ What were the circumstances surrounding the incident? (describe incident in detail): What personal protective equipment (PPE) was being used?: What actions were taken? (decontamination, clean-up, reporting, etc.): Was the source individual documented? If so, was exposed employee made aware of the serological status of the source individual? Did the employee receive the healthcare professional's written opinion following examination? Recommendations For Avoiding Repetition: Supervisor/Manager:__________________   Date:__________