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Contact Us

350 Capitol Street
Room 125
Charleston, WV 25301

Phone: (304) 558-2195
Hotline: (800) 642-8244

Reporting Forms

All of the reporting forms used by the Needlestick Injury Prevention Program have been revised for use beginning with January 1, 2010 injuries. Please be sure to use the correct forms when reporting 2010 injuries.  

Reporting Instructions (Revision Date: 01/01/2010)   
                                PDF Format  

Individual Needlestick and Sharp Object Injury Report (Revision Date: 11/2009)   
                                PDF Format 
                                Use for printing to complete by hand.   
                        
                                Editable PDF Format
                                Use to complete electronically.

Quarterly Needlestick and Sharp Object Injury Report (Revision Date: 01/01/2010)   
                                PDF Format 
                                Use for printing to complete by hand.   

                                
Editable PDF Format
                                Use to complete electronically.
        
Annual Needlestick and Sharp Object Injury Report (Revision Date: 01/01/2010)   
                                PDF Format 
                                Use for printing to complete by hand.   

                                Editable PDF Format
                                Use to complete electronically.

Needlestick Reporting Contact Information Form (Revision Date: 01/01/2010)   
                                PDF Format 
                                Use for printing to complete by hand.   

                             
 

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