Date: _________ Received From Campus: __________________________

Found by: ___________________ Item(s) Found: _________________________

Did Penetration Occur to Employee? ____No ____Yes
If yes, by whom? _________________________________________________________

Was Treatment Received? ____No ____Yes
If yes, by whom? ________________________________________________________

_______________________________________________________________
What Treatment was Received?
________________________________________________________________

________________________________________________________________
Has Employee Received Hepatitis B Vaccine? ________ Yes ________ No

Any Other Medical Conditions or Considerations?
________________________________________________________________

________________________________________________________________

________________________________________________________________

Employee Signature: ____________________________

Supervisor Signature: _____________________________

Was Item Returned to Facility? ____ Yes _____ No

Date Returned: _________ To Whom?: ______________________________________

Returned By: _____________________________________________________________

This form shall remain on file.