Environmental Health & Safety	E H & S TEL NO: (818) 677-2401 FAX NO: (818) 677-5853 MAIL DROP: 8284
	Sharp's Injury Log

I. EXPOSED EMPLOYEE INFORMATION:
Exposed Employee Last Name:		Exposed First Name:
Job Classification		Department:

II. EXPOSURE INCIDENT INFORMATION:
1. Date & Time of Exposure Incident:
2. Type and Brand of sharp involved in the exposure incident:
3. Department of work area where the exposure incident occurred:
4. The procedure that the exposed employee was performing at the time the incident occurred:
5. How did the incident occur?
6. What was the body part involved in the exposure?
7. Did the sharp have engineering sharps injury protection?
	NO - (Proceed to Question #9) YES - Was the protective mechanism activated: YES NO Did the injury occur before, during, or after the protective mechanism was activated? BEFORE DURING AFTER
8. If the sharp did not have an engineered sharps injury protection, the injured employee's opinion as to whether and how such a mechanism could have prevented the injury:
9. The employee's opinion about whether any other engineering, administrative or work practice control could have prevented the injury:

Employee Signature: ______________________________________________ Date: _________________