Report • CampusOptics

Use this form to report incidences involving blood-borne pathogen exposure.

In an emergency, SEEK IMMEDIATE MEDICAL ATTENTION.

- For on-campus injuries, call FIU Police at 305-348-5911 (MMC) or 305-919-5911 (BBC)

- For off-campus injuries, call 911

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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Department

Have you received a Hepatitis B vaccine?

Date of Hepatitis B Vaccine

Potentially infection materials involved

Source an individual or supplier?

Individuals Name

Health status of the individual known?

Follow-up medical treatment provided?

Description of task performed

Where follow-up treatment provided?

Identify the route of exposure

PPE used

Incident reported to other groups?

Other groups reported

Witnesses Present?

List witnesses

Form on behalf of someone else?

Add files to upload as supporting documentation along with your incident.