Medical Facility Chemical Spill Report
Date of Spill
Time of Spill
Location of Spill
Department/Area
Description of Chemical(s) Involved
Quantity Spilled
Cause of Spill
Personnel Involved
Immediate Actions Taken
Exposure or Injury?
No
Yes
If Yes, Provide Details
Additional Comments/Observations
Reported By (Name & Title)
Date Reported