Personal Injury Laboratory Accident Report
Name of Person Reporting
Date of Report
Name of Injured Person
Role (e.g., Student, Staff, Visitor)
Date of Incident
Time of Incident
Location of Incident (Building & Room)
Description of Incident
Nature and Extent of Injury
Apparent Cause of Accident
Witnesses
Immediate Actions Taken (First Aid, etc.)
Follow-up/Preventive Measures
Supervisor Notified