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Get Michigan State University Sharps Injury Log 2010

Al Security No. Name of Claimant: Telephone: Name of Supervisor: Date of Birth: Male Female Department: Building and area of injury: Date of Injury: Time of Injury: a.m or p.m Fill in the one circle corresponding to the most appropriate answer. Description of the exposure incident: Job classification: Ο MD Ο Nurse Ο Medical assistant Ο Phlebotomist/Medical Lab Tech Ο Housekeeper/Laundry Ο Research Lab Tech Ο Student, type Ο Other Procedure: Ο Draw venous blood Ο Draw arteri.

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