LAB INCIDENT REPORT

Complete this form when there is an incident that occurs regarding incident related to lab deliveries.

Driver's Name: *

Driver No. *

Phone *

Email *

Date of the Incident: *

Type of Exposure (check one): *

No Risk (as in lost specimen(s)

Low Risk (defined as intact skin, ability to wash immediately, as in spill)

Medium Risk (defined as intact skin but possible exposure through nose, eyes or mouth (spill)

High Risk (defined as broken skin, as in needle stick or puncture)

Details of Incident: *

Client Involved: *

TDDC

SynergenX

TCRS

Name of the Person Notified or Who Notified Us: *

Contact Information for Client Representative: *

Name of Patient(s):

Was Sample Destroyed? *

Yes

No

Unknown

Type of test(s): *

Impact on Patient: *

Impact on Client: *

Other Pertinent Information: *

Resolution: *

By signing this form, I acknowledge that I have completed this for the purposes of reporting the incident. Submission of this form does not in any way assign fault for the incident.

By submitting this form, you agree to terms & conditions provided by Paragon Accelerated Couriers and by providing your phone number, you agree to receive text messages from the business.

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