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    Needle Stick Injury Form

    Uploaded by

    Usma-i- Rasool
    This document is a needle stick injury form used by Chughtai Lab. It collects information about needle stick injuries including: the employee and patient details, exposure details like the type of sharp and site of injury, risk level for transmitting diseases, medical attention provided, and preventive measures discussed. The form is filled by collecting information from the victim employee and investigating the incident. It requires signatures from the quality manager and medical officer.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Needle Stick Injury Form

    Uploaded by

    Usma-i- Rasool
    783 views3 pages
    This document is a needle stick injury form used by Chughtai Lab. It collects information about needle stick injuries including: the employee and patient details, exposure details like the type of sharp and site of injury, risk level for transmitting diseases, medical attention provided, and preventive measures discussed. The form is filled by collecting information from the victim employee and investigating the incident. It requires signatures from the quality manager and medical officer.

    Original Title

    074. Needle Stick Injury Form

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    This document is a needle stick injury form used by Chughtai Lab. It collects information about needle stick injuries including: the employee and patient details, exposure details like the type of sharp and site of injury, risk level for transmitting diseases, medical attention provided, and preventive measures discussed. The form is filled by collecting information from the victim employee and investigating the incident. It requires signatures from the quality manager and medical officer.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    783 views3 pages

    Needle Stick Injury Form

    Uploaded by

    Usma-i- Rasool
    This document is a needle stick injury form used by Chughtai Lab. It collects information about needle stick injuries including: the employee and patient details, exposure details like the type of sharp and site of injury, risk level for transmitting diseases, medical attention provided, and preventive measures discussed. The form is filled by collecting information from the victim employee and investigating the incident. It requires signatures from the quality manager and medical officer.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    CHUGHTAI LAB (CL)

    QSP/QF/L4/074 Needle Stick Injury Form Rvw/Rev: 6.0/6.0

    Issue on: 19-06-2013 Review Date: 07-04-2022 Revision Date: 07-04-2022 DCR#: 132/2022

    Needle Stick Injury Form


    NSI Form no.

    Employee Name: Employee Code: Department/Center:

    _______________________________ _________________________ ______________________________

    Accident Date: (dd-mm-yyyy) Patient/Resource Case no.: Victim Case no.: Patient Contact no.:

    _________________________ ______________________ ______________ _______________________

    A. Exposure Information
    Type of sharp: (check all applicable) Site of Injury: (check all applicable)

    Syringe Vacutainer Razorblade/scalpel/Slide Finger Leg (Lower) Mucous Membrane

    Wire Needle Other _______________ Hand Leg (upper) Percutaneous

    Description of Injury:
    ________________________________________________ Arm Skin Other___________
    ________________________________________________
    Source of Injury: (check all applicable) Sharp device used in (Check all applicable):

    Artery Vein
    Blood Fluid Visible with blood Vaginal Fluid

    Subcutaneous Tissue Intramuscular


    Semen Pericardial Fluid CSF
    Was the skin of victim intact prior to infection?

    Yes No
    Synovial Fluid Other _______________________

    B. Source Material & Risk Transmission


    Note: Based on your investigation, please provide your best estimate of risk associated with this injury

    Risk of HIV Risk of Hepatitis B/C

    Low Medium High Low Medium High

    Resource Person (Patient) Source material known to contain:

    MASTER Page 1 of
    Occupational Health and Safety Manual
    CHUGHTAI LAB (CL)
    QSP/QF/L4/074 Needle Stick Injury Form Rvw/Rev: 6.0/6.0

    Issue on: 19-06-2013 Review Date: 07-04-2022 Revision Date: 07-04-2022 DCR#: 132/2022

    Human Immunodeficiency Virus (HIV) Hepatitis C Virus (HCV) Hepatitis B Virus Unknown

    C. Medical Attention
    Check all appropriate boxes and provide details if available

    Employee Health Services Hospital Emergency Family Physician


    Description: ___________________________________________________________________________

    The Victim received: (check all applicable)

    HIV PEP Medication HBV Vaccine Tetanus

    Yes No Yes No Yes No

    Date of Last Booster: ___________________________________________________________________


    D. Prevention

    Counselling
    If yes, provided by
    ______________________________________________
    Yes No

    Preventive Measure Discussion The worker’s level of anxiety is

    Yes No Low Medium High

    Remarks by QM:
    ______________________________________________________________________________
    ______________________________________________________________________________

    Signature: ______________________

    Remarks by MO:

    ______________________________________________________________________________
    ______________________________________________________________________________

    MASTER Page 2 of
    Occupational Health and Safety Manual
    CHUGHTAI LAB (CL)
    QSP/QF/L4/074 Needle Stick Injury Form Rvw/Rev: 6.0/6.0

    Issue on: 19-06-2013 Review Date: 07-04-2022 Revision Date: 07-04-2022 DCR#: 132/2022

    Signature: ______________________

    MASTER Page 3 of
    Occupational Health and Safety Manual

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