Needlestick & Sharp Object Injury Report    

Click Submit to send completed form to the West Virginia Needlestick Injury Prevention Program, 350 Capitol Street, Room 125, Charleston, WV 25301. 

Please email all inquiries to needlestickreporting@wv.gov

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Email *
Facility Code *
Submitted By Last Name *
Submitted By First Name
 *
Facility Name *
1) Date of Injury *
MM
/
DD
/
YYYY
2) Time of Injury (24-hour format)
Time
:
5) What is the Job Category of the Injured Worker? (Select One Category)
5.1) If Job Category is Doctor (attending/staff), Specify Specialty
5.2) If Job Category is Doctor (intern/resident/fellow), Specify Specialty
5.4) If Job Category is Nurse (Select ONLY One)
5.15) If Job Category is Other, Please Describe
6) Where Did the Injury Occur? 
6.4) If Where Injury Occurred is Intensive/Critical Care Unit, Specify Type
6.14) If Where Injury Occurred is Other, Please Describe
7) Was the Source Patient Identifiable?   
8)  Was the Injured Worker the Original User of the Sharp Item?  
9) The Sharp Item was: 
9.1) If Sharp Item  was Contaminated,  was there blood on the device?
Clear selection
10) For What Purpose was the Sharp Item Originally Used?  
10.7 & 8) If used to draw blood was it a...
10.15) If Other Purpose, Please Describe
11)  Did the Injury Occur?   
11.14) If Other Injury Occurrence, Please Describe
12) What Type of Device Caused the Injury?  
12a) Which Device Caused the injury?  Needle/Surgical/Glass Device Caused the Injury?  
12.1) If Disposable Syringe, what Type?   
12.29 & 59 & 79) Other Device,  Please Describe    

12.a) Brand/Manufacturer of Product (e.g. ABC Medical Company)
12b) Model
Clear selection
12b) If Known, Please Specify Model:

13) If the Item Causing the Injury was a Needle or Sharp Medical Device, Was it a” Safety Design” with a Shielded, Recessed, Retractable, or Blunted Needle or Blade?

13.a) Was the Protective Mechanism Activated?
13.b) Did Exposure Incident Happen? 
14) Specify Location of the Injury
Captionless Image
15) Was the Injury?

16) If Injury was to the hand, did the Sharp Item Penetrate?

17) Dominant Hand of the Injured Worker?

18) Describe the Circumstances Leading to this Injury (please note if a device malfunction was involved)

19)  For Injured Healthcare Worker:  If the Sharp had no Integral Safety Feature, Do you have an Opinion that such a Feature could have prevented the Injury?
19a) Describe:
20)  For Injured Healthcare Worker:  Do you have an Opinion that any other Engineering Control, Administrative or Work Practice could have prevented the Injury?
20a) Describe:
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