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STATE OF CALIFORNIA-DEPARTME -HEALTH SERVICES <br /> UNIVERSITY OF CALIFORNIA-SAN F ISCO <br /> OCCUPATIONAL HEALTH BRANCH <br /> 1515 Clay Street,Suite 1901 <br /> Oakland,CA 94612 <br /> (510)622-4300 <br /> FAX(510)622-4310 <br /> Sharps Injury Record-Keeping Checklist <br /> Developed by Sharps Injury Control Program <br /> for DHS, Medical Waste Management Inspectors <br /> Please fill in the information below: <br /> Your Name: Generator/Facility Name: <br /> Your Work Address: Facility Address: <br /> �D ,�toC <br /> Your Phone Number: Facility Contact Name: <br /> ( ) r t 7( ' Contact Phone Number: ( ) <br /> `1 (Optional.Fill in if facility is requesting further <br /> information about the Sharps Log from the Sharps <br /> Injury Control Program) <br /> Information on How the Facility Records and Tracks Sharps Injuries: <br /> 1. I requested the facility's sharps injury to es No <br /> 2. I reviewed the to es No <br /> 3.The facility declined to show the log to me. Yes No <br /> 4.The facility maintains a sharps injury log that tracks sharps injuries including tune and Yes No <br /> brand of device. <br /> 5. I am forwarding a copy of the log to the Sharps Injury Control Program. Yes No <br /> Please send copies of the Log to: <br /> Jim Cone,MD,MPH OR Martha Davis,MSPH,EMT <br /> Chief,Occupational Health Branch Program Director,Epidemiologist <br /> Project Officer,Sharps Injury Control Program Sharps Injury Control Program <br /> (address above) (address above) <br /> Thank you for your assistance. <br /> Draft 03/09/99 <br />