Forms & requests

Staff injury or exposure report

Hurt at work, or exposed to blood or body fluids? Report it the same day, even if it seems minor. This is about your safety, not blame.

Exposed to blood or body fluids? Wash the area now, tell your supervisor right away, and get a medical evaluation the same day. Treatment to prevent infection works best within hours.

Serious injury or death: call 911, then call leadership immediately. Don’t wait for this form.

Your name

Your supervisor

Date of injury

Time

Where did it happen? Type

Wash the area now, tell your supervisor right away, and get a medical evaluation the same day. Treatment to prevent infection works best within hours.

Body part affected What happened?

What were you exposed to?

Never write a client’s name. Leadership handles any source testing privately.

Is the source person known?

YesNo

Medical treatment

Missed work after the day of injury?

Witnesses (optional) Photos or medical paperwork (optional)

Saved to a restricted employee health folder only leadership can open, never your training file.

Staff injury or exposure report

Report received.