Route of exposure: (i.e., Splash, needlestick, bite, etc.) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Which personal protective equipment was being used? (i.e., Gloves, etc.) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
I verify that the information above is correct and accurately describes the exposure incident in which I was involved.
_________________________________
__________
Exposed Individual’s Signature
Date
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Dental Hygiene Program
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