Incident Form

The Sun Home Health Care Delaware The Sun Home Health The Sun Home Health Care Columbus The Sun Adult Day Care

Please insert an answer of the blanks into this text box.

Please insert an answer of the blank into this box.

Vital signs (if applicable) when the incident is supine and at one and three minutes after standing till unable to stand use supine to sitting position

Initial Incident Supine

One Minute After Standing

Three Minute After Standing

Temperatures

Pulse

Respirations

Blood Pressure

Faces Blood Urine Sputum

Needle stick Bite Spalsh Spill

Yes

Known to be HBV/HCV infected?

Legally obtained consent of HBV/HCV and or HIV infection test?

Known to be HIV infected?

Results of testing made know to employee?

Yes

Informed of applicable laws and regulations concerning disclosure of identity
and infectious status of source individuals?

Legally obtained consent for HBV/HCV and/or HIV infectiviy testing?

Post exposure prophylactics due?

Referred for medical evaluation and blood testing?

Manage investigating the incident must complete this section. Explain in detail what follow-up was initiated related to the incident, interventions taken to prevent recurrence and who is responsible for implementation, as well as when the corrective action will be implemented. Submit to the Director/Administrator when the investigation of the incident is complete.

Unsafe work procedure/practice Unsafe work condition Impropar equipment/tools

Human Resources Manager Notified Review of agency policy and procedure with staff Worker’s Compensation Report filed Review of agency and procedure with patient/family member Exposure Protocol follow-up initiated

Incident Report

Directions

Section 1

Section 2

Section 3

Section 4

Section 5

Incident Assessment

Staff Injury only

Follow-Up Related to the incident

Date corrective action will be implemented