Republic of the Philippines

Province of Negros Occidental

City of San Carlos
SAN CARLOS CITY HOSPITAL
Hda. Sta. Ana (C2 Road) Barangay Palampas, San Carlos City, Negros Occidental
Trunkline Nos. (034) 312-5661/ 312- 5663 (034) 312-5771/ 312- 5773
E-mail add: scchospital@yahoo.com

SHARP INJURY FORM/ NEEDLESTICK REPORT

Instruction: This needle stick or sharp injuries form is to be used by the

San Carlos City Hospital as an addendum to the report of injury,
witness, statement, and Supervisors Investigation reports.

EMPLOYEE INFORMATION

Employee’s Name : ___________________________________ Male _____ Female _____

Date of birth: ______________________ Contact Number: __________________________

Home address: ______________________________________________________________

Employment classification: Regular ( ) Job Order ( )

Vaccines received: Tetanus ( ) Hepa A ( ) Hepa B ( )

INJURY INFORMATION

Date of Incident: ________________ Place of Incident : ____________________________

Body part/s affected or injured: ________________________________________________

Type of needle/ sharp: ________________________________________________________

Brief description of the incident: ________________________________________________

___________________________________________________________________________

___________________________________________________________________________

MANAGEMENT/ TREATMENT

Attending Physician : _______________________________________________________

Laboratory examination: ____________________________________________________

Medications : _____________________________________________________________

Name of Supervisor _______________________________ Contact #: ________________

Signature of Employee: _______________________________________________________