Report • CampusOptics

Note to Clinical Instructor or Supervisor: Print this form, and ensure a completed copy is delivered to Human Resources (HR) Dept 1016 within 24 hours of the incident. If you have questions, contact HR at hr@weber.edu or by phone: 801-626-6184

Workers Compensation Insurance Information: Blood exposure to a WSU employee or student intern is covered under the university’s policy. If you or the health care agency have any questions, contact WSU’s coordinator at Phone: 801-626-6184.

Please note: For "Location" below, type a name or address to search buildings and outdoor areas on campus. If off campus, select "Off Campus" for "Campus, Building, or Outdoor Area."

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Exact Location

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Exposed Individual's Information

Exposed Individual's Status

Exposed Individual's Name

Exposed Individual's W#

Exposed Individual's Home Address

Exposed Individual's Home/Cell Phone

Exposed Individual's Work Phone

Exposed Individual's Date of Birth

Exposed Individual's Gender Assigned at Birth

Exposed Individual's Date of Hire

Exposed Individual's Job Title

Exposed Individual's Employee Type

Exposed Individual's Employment Status

Exposed Individual's Department/Program

Exposed Individual's Supervisor

Exposed Individual Supervisor's Phone

Exposure Information

Exposure Date

Exposure Time

Witness Name & Phone Number

Type and Model of Device Involved

Type of protection equipment used

Route of exposure

How to prevent

Medical Treatment

Doctor/Facility

Address of Medical Facility

Telephone of Medical Facility

Signature Section

Employee Signature

Exposed Individual's Signature

Witness' Signature

Add Supporting Documents

Add files to upload as supporting documentation along with your incident.