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Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program


Contents:

APPENDIX A - TOOLKIT

This toolkit contains a variety of sample forms that may be downloaded for use by healthcare organizations in developing or enhancing an organization’s sharps injury prevention program. These forms may be adapted as desired to best meet the organization’s needs. Each form is linked to a workbook section that describes the context in which use of the form is intended.

A-1 Baseline Program Assessment Worksheet
A-2 Survey to Measure Healthcare Personnel Perceptions of a Culture of Safety
A-3 Survey of Healthcare Personnel on Occupational Exposure to Blood and Body Fluids
A-4 Baseline Institutional Injury Profile Worksheet
A-5 Baseline Injury Prevention Activities Worksheet
A-6 Sharps Injury Prevention Program Action Plan Forms
A-7 Blood and Body Fluid Exposure Report Form
A-8 Sharps Injury Hazard Observation and Report Forms
A-9 Sample Form for Performing a Simple Root Cause Analysis of a Sharps Injury or "Near Miss" Event
A-10 Occupation-Specific Rate-Adjustment Calculation Worksheet
A-11 Survey of Device Use
A-12 Device Pre-Selection Worksheet
A-13 Device Evaluation Form
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This workbook developed and maintained by CDC's
Division of Healthcare Quality Promotion - (DHQP Home)
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Publish date: February 12, 2004
This page last reviewed February 12, 2004
Get Acrobat Reader CDC Home - CDC Search - CDC Health Topics A-Z

This workbook developed and maintained by CDC's
Division of Healthcare Quality Promotion - (DHQP Home)
Privacy Policy - Accessibility

Publish date: February 12, 2004
This page last reviewed February 12, 2004