New Jersey Department of Health

Public Health Sanitation and Safety Program

PO Box 369

Trenton, NJ 08625-0369	CONFIDENTIAL

MEDICAL WASTE EXPOSURE REPORT

FOR STATE USE ONLY
Case Number

Date

Type of Exposure

Beach Community Occupational
All sections must be completed. If information is not available, write “N/A.”

A. GENERAL INFORMATION
Name of Victim (First, MI, Last)

Age

Sex

Male Female
Local Address

Permanent Address (if different from Local)

City, State, Zip

City, State, Zip

Telephone Number

( )	Telephone Number

( )
Date of Incident (mm/dd/yy)

____/____/____	Time (hh:mm)

____:____	AM PM	Parent/Guardian Contact

Date

Date Reported to NJDOH

____/____/____	Time

____:____	AM PM	Received By

Name of Agency Reporting Incident

Telephone Number

( )
Name of Official

Title of Official

Location of Incident:
Street Address/General Area:
City/Town/Locality:
County:
Description of Item Found

Type of Item

Syringe Barrel Only Needle Only

Other: _________________________
Is Fluid Present?

Yes No	Approximate Amount, if Known

Comments

B. MEDICAL INFORMATION
Type of Item

Needle Puncture	Intact Skin	Laceration

Fluid Contact	Non-Intact Skin	Body Part: _________________________

Other: _________________________
First Aid Administered?

Yes No	By Whom (if known):

Medical Treatment Rendered Prior to NJDOH Consult?

Yes No	By Whom (Doctor/Hospital):

Telephone Number

( )
Vaccination Status and NJDOH Recommendations:
Last Tetanus Vaccination:
HIV Serological Testing Recommended?	Yes No
Performed?	Yes No	Date:
Hepatitis B Vaccination Recommended?	Yes No
Initiated?	Yes No	Date:
Hepatitis B Vaccination Refused?	Yes No
HIV Counseling Recommended?	Yes No
NJDOH Physician Contacted?

Yes No	Name of Physician:

If Yes, Date Contacted (mm/dd/yy)

____/____/____	Time (hh:mm)

____:____	AM PM
Specific Comments:

Victim’s General Comments:

Other Information:

CONFIDENTIAL MEDICAL WASTE EXPOSURE REPORT

(Continued)

PHSS-6

JUL 12	Page 2 of 2 Pages.

JUL 12	Page 1 of 2 Pages.

PHSS-6, Confidential Medical Waste Exposure Report

PHSS-6, confidential, medical waste, exposure report, public health sanitation and safety, needle stick,

ewhite

2010-04-15

NJDHSS