Laboratory Equipment Malfunction Accident Report
Reporter Information
Name
Department / Lab
Date of Report
Equipment Information
Equipment Name
Equipment ID / Serial Number
Location
Incident Details
Date of Incident
Time of Incident
Description of Malfunction / Accident
Immediate Actions Taken
Injury / Damage
Was there any injury or property damage?
No
Injury
Property Damage
Both Injury and Damage
If yes, please provide details
Follow-up
Has this been reported to supervisor/manager?
Yes
No
Additional Comments