Form 315-2
Employee Exposure Incident
/ Box 700, Rosetown, Sask., S0L 2V0
Phone: (306) 882-2677 Fax: (306) 882-3366
Toll Free: 1(866) 375-2677, www.sunwestsd.ca / Reference / AP 315 Illness/Injuries at School
Revised / July 25, 2013
Level / Division
Submit to / Human Resources Supervisor
When / As Required

Confidential: To be completed by employee at the time of incident.

Exposed Employee Information

Employee Name
Address
Phone Number
Employee Category
Teacher / Caretaker / Educational Assistant / School Librarian
Bus Driver / School Secretary / Other (specify)
Incident Location:
Type of Incident (i.e. playground accident, medical emergency, cuts, etc):
Exposure Description:
Date of Exposure: / Time of Exposure:
What body fluid(s) were you in contact with?
Blood / Feces / Saliva / Sputum
Sweat / Tears / Urine / Vomitus
Other (describe):
What was the method of contact?
Needlestick with contaminated needle
Blood or body fluids into natural body openings (eg: nose, mouth, eye)
Blood or body fluids into cut, wound, sores, or rashes less than twenty four hours old
Please specify:
Blood or body fluids on intact skin
Other (describe specifically):
How did the exposure occur? (Be Specific)

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What action was taken in response to the exposure to remove the contamination? (i.e. hand washing)
What personal protective equipment was being used at the time of exposure?
Was there a failure of the protective equipment? / Yes / No
If yes, explain:
Please describe any other information related to the incident (use a separate piece of paper if needed):
Source of Exposure:
Name of Person Source of Exposure: / Gender:
Receiving Health Care Facility (if applicable):
Transported by: (if applicable):
Employee’s Signature / Date
Principal/Supervisor’s Signature / Date

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