11/8/2004 12:38:45 PM

Department of State Health Services

InfectiousDisease Control

Contaminated Sharps Injury Reporting Form

Please complete a form for each exposure incident involving a sharp.

NOTE: If injury occurred BEFORE the sharp was used for its original intended purpose, do not submit this form.

Facility where injury occurred:
Street address (no PO Box):
City: / County: / Zip Code:
Street address of reporter (if different from above): / Date filled out:
Reporter’s Name: / Phone: -- / Reporter’s e-mail:

INSTRUCTIONS FOR DROP-DOWN LIST: Choose (one) response from Drop-down list or enter answer in “Other” field.

1. Date of injury: / / / / Time of injury: am pm
Age of injured: / Sex of injured: / Male Female
2. Type of Sharp Involved:
(Choose only one response from Needles, Surgical Instruments, or Glass Drop-down Lists).
List Brand Name of Sharp: / Needles List Arterial Catheter Introducer NeedleBlood Gas SyringeCentral Line Catheter Needle (cardiac, etc.)Disposable Syringe-InsulinDisposable Syringe-20-gauge needleDisposable Syringe-21-gauge needleDisposable Syringe-22-gauge needleDisposable Syringe-23-gauge needleDisposable Syringe-24/25-gauge needleDisposable Syringe-TuberculinDrum Catheter NeedleIV Catheter StyletNeedle on IV Line (piggybacks/IV connectors)Needle, not sure what kindNon-vascular Catheter (ophthalmology)Pre-filled Cartridge SyringeSpinal or Epidural NeedleSuture NeedleSyringe, other typeUnattached Hypodermic NeedleVacuum Tube Blood Collection Holder/NeedleWinged Steel Needle (butterfly/winged-set)Other Vascular Catheter Needle (cardiac, etc.) or Other Non-suture needle
Surgical Instruments List Bone Chip/Chipped ToothBone CutterDrill Bit/BurElectro-cautery DeviceFingernails/TeethHuber NeedleLancet (finger or heel stick)Microtome BladePickups/Forceps/Hemostats/ClampsPin (fixation, guide pin)Pipette (plastic)RazorRetractors, Skin/Bone HooksScalpel, disposableScalpel, reusableScissorsSharp Item, not sure what kindSpecimen/Test Tube (plastic)Staples/Steel SuturesTowel ClipTrocarVacuum Tube (plastic)Wire (suture/fixation/guide wire) or Other Surgical
Glass Items List Capillary TubeGlass SlideGlass Item, not sure what kindMedication Ampule/Vial/IV BottlePipetteSpecimen/Test TubeVacuum Tube or Other Glass
3. Original Intended Use of Sharp / A-I Connect IV Line (piggyback/other IV line connectContain a Specimen or Pharmaceutical (glass item)CuttingDental ExtractionDental HygieneDental OrthodonticDental PeriodontalDental RestorativeDental Root CanalDialysisDraw Arterial Blood Sample-direct stickDraw Arterial Blood Sample-drawn from a lineDraw Venous Blood SampleDrillingElectrocauteryFinger Stick/Heel StickHeparin or Saline FlushIM/Subq/ID/Other injection through skin O-ZObtain a Body Fluid or Tissue SampleOther Injection into (or aspiration from) IVRemove Central Line/Porta CatheterStart IV or Set Up Heparin LockSuturing-DeepSuturing-SkinTattooUnknown/Not ApplicableWiringOther (specify) or Other
4. When and How Injury Occurred…
before (DO NOT report to DSHS)
during
after the sharp was used for its intended purpose. / 4.A If the exposure occurred during or after the sharp was used, was it…
How Exposed List Activating Safety DeviceBetween Steps of a Multistep Procedure (carrying,*Device MalfunctionedDevice Pierced the Side of the Disposal ContainerDisassembling Device or EquipmentFound in an Inappropriate Place**Interaction with Another PersonLaboratory Procedure/ProcessPatient Moved During the ProcedureRecappingSuturingUnsafe PracticeUse of IV/Central LineUse of Sharps ContainerOther (specify) or Other
5. Did the device being used have engineered sharps injury protection? / yes no don’t know
A. Was the protective mechanism activated? / yes, fully yes, partially no don’t know
B. Did the exposure incident occur… / before during after activation of the protective mechanism?
6. Was the injured person wearing gloves? / yes no
7. Had the injured person completed a hepatitis B vaccination series? / yes no don’t know
8. Was there a sharps container readily available for disposal of the sharp? / yes no
8.A Did the sharps container provide a clear view of the level of contaminated sharps? / yes no
9. Had the injured person received training on the exposure control plan in the 12 months before the incident? / yes no
10. Involved body part: / ______HandArmLeg/FootFace/Head/NeckTorso (front or back)
11. Job Classification of Injured Person / A-LAide (eg. CAN, HHA, orderly)Attending Physician (MD/DO)Central SupplyChiropractorClerical/AdministrativeClinical Lab TechnicianCounselor/Social WorkerCRNA/NPDentistDental Assistant/TechnicianDental HygienistDental StudentDieticianEMT/ParamedicFellowFirefighterFood ServiceHemodialysis TechnicianHousekeeper/LaundryIntern/ResidentLaw Enforcement OfficerLicensed Vocational Nurse M-ZMaintenance StaffMorgue Tech/Autopsy TechnicianMedical StudentNurse MidwifeNursing StudentOR/Surgical TechnicianPharmacistPhlebotomist/Venipuncture/IVTeamPhysician AssistantPhysical TherapistPsychiatric TechnicianPublic Health WorkerRadiologic TechnicianRegistered NurseResearcherRespiratory Therapist/TechnicianSafety/SecuritySchool Personnel (not a nurse)Transport/MessengerVolunteerOther (specify) or Other (specify)
12. Employment Status of Injured Person / ______Contractor/Contract EmployeeEmployeeStudentVolunteerOther (specify) or Other (specify)
13. Location/Facility/Agency
in Which Sharps Injury Occurred / ______Blood Bank/Center/MobileClinicCorrectional FacilityDental FacilityEMS/Fire/PoliceHome HealthHospitalLaboratory (freestanding)Medical Examiner Office/MorgueOutpatient treatment (dialysis,infusion)Residential Facility (eg. MHMR, shelter)School/CollegeOther (specify) or Other (specify)
14. Work Area Where Sharps Injury Occurred / A-LAmbulanceAutopsy/PathologyBlood Bank Center/MobileCentral SupplyCritical Care UnitDental ClinicDialysis Room/CenterEmergency DepartmentEndoscopy/Bronchoscopy/CystoscopyField (non EMS)Floor, not Patient RoomHomeInfirmaryJail UnitLaboratoryL & D/Gynecology Unit M-ZMedical/Outpatient CliniicMedical/Surgical UnitNurseryPatient/Resident RoomPediatricsPre-op or PACUProcedure RoomRescue Setting (non ER)Radiology DepartmentSeclusion Room/Psychiatric UnitService/Utility Area (eg. laundry)Surgery/Operating RoomOther (specify) or Other
COMMENTS (your notes, opinions, suggestions)

INSTRUCTIONS: The facility where the injury occurred should complete the form and submit it to the local health authority where the facility is located.

If no local health authority is appointed for this jurisdiction, submit to the regional director of the Department of State Health Services regional office in which

the facility is located. Address information for regional directors can be obtained on the Internet at .

The local health authority, acting as an agent for the Department of State Health Services will receive and review the report for completeness, and submit

the report to: Texas Department of State Health Services, Infectious Disease Control (IDC), Mailcode 1960PO Box 149347 Austin, Texas 78714-9347.

Copies of the Contaminated Sharps Injury Reporting Form can be obtained on the Internet at

or from Department of State Health Services regional offices.

Pub No EF59-10666 (6/04)