ONLY COMPLETE THE FOLLOWING FORM IF YOU HAVE SUSTAINED A SHARPS INJURY/BLOOD OR BODY FLUID EXPOSURE CONTAMINATED WITH HUMAN BLOOD OR BODY FLUIDS. 

 ***THIS IS NOT THE PSH WORKER'S COMPENSATION INJURY REPORT!!!

For your safety, please be sure you have washed the injury site with soap and water or flushed the affected splash site prior to completion of this questionnaire.

You will be asked to contact a supervisor or leadership person in the unit or area where you were injured. This is important as you will need assistance from this individual.

To expedite care for your invasive incident (sharps injury or blood/body fluid splash), please answer the following questions.

After you submit the questionnaire you will be given a VICTIM NUMBER that you will need for your care.

AN INDIVIDUAL WHO SUSTAINS A SHARPS INJURY OR BLOOD/BODY FLUID SPLASH IN THE MAIN OPERATING ROOM/ CHILDREN'S OPERATING ROOM OR SOUTH OPERATING ROOM SHOULD CONTACT CLINICAL LEAD FOR A "PACKET" TO ASSIST WITH THIS PROCESS.

**The instructions to obtain source (patient) blood are contained in the supervisor instructions in this process once you submit and download your information, along with an attachment for source labs (including what tubes are needed) and source HIV consent.

Thank you!

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