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4112.4, 4212.4E_Exhibit A Incident-Report-Form

Northfield Board of Education file code: 4112.4/4212.4

X Monitored

X Mandated

Exhibit A X Other Reasons

Northfield Public School District
2000 New Road

Northfield, NJ 08225



In the event of an incident involving the exposure of a staff person or student to blood or other potentially infectious materials, this form, as required by the Occupational Safety and Health Administration (OSHA), shall be completed as soon as possible. The information collected below is intended to assist with evaluating the control methods used and with preventing future exposures.


Name of Person(s) Exposed:

(indicate if staff or student)

District School:

Incident Date: Time:

Incident: Mark in each column, as appropriate

Exposure: Injury Type/Exposure Route: Body Part Injured:

Blood Abrasion Finger

Other Body Fluids Laceration Hand

Specify:_______________ Puncture Arm

Was blood seen in body fluid? Mucous Membrane Eye

Yes ____ No ____ Human Bite Other:___________

Infectious Material Other______________


Other __

Description of Incident:

Protective equipment in use at time of incident:

Gloves Protective Sleeves Other

Goggles Lab Coat

Face Mask/shield Gown

Referred to: ___________________________________________________________________

No Medical Treatment sought Emergency Treatment Center

Policy 4112.4/4212.4 Employee Health (covering exposure to bloodborne pathogens)

All staff are trained and familiar with policy 4112.4/4212.4

Engineering controls in place at the time of the exposure incident:

The term “engineering controls” includes all control measures that isolate or remove a hazard from the workplace, encompassing not only sharps with engineered sharps injury protections and needleless systems but also other medical devices designed to reduce the risk of percutaneous exposure to bloodborne pathogens. Examples include sharps disposal containers and biosafety cabinets.

The work practices and protective equipment or clothing used at the time of the exposure incident:

Notation of any “failures to control” at the time of the exposure incident:

What changes need to be made to prevent reoccurrence?

Report prepared by: __________________



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