MOCK EXPOSURE$/$INCIDENT FORM PROJECT GUIDELINES

HEALTH & SAFETY MSS$154$

Create an incident for an exposure that is related to your field of study. You will be responsible for filling out a detailed incident report.

The name of the facility will be Sullivan University Hospital. You will create the name of the victim and staff members involved.

Examples of Exposures:

a$.$ Needle stick

b$.$ Chemical spill

c$.$ Radiation exposure

d$.$ Other idea?

Please give a detailed description of your incident. $($Don$\text{'}$t forget to add the witnesses$)$

Incident Report

All items must be completed:

Check one:

Campus, Hospital, or location: Student

Name of Party:

Employee

Address:

City, State, Zip:

Phone number:

SSN:

Date of Birth:

Incident

Date:

Time:

Location:

Description with as much detail as possible:

Signature of Party

Signature of Director Hospital