Laboratory Chemical Inhalation Incident Form
Basic Information
Date of Incident
Time of Incident
Location (Building/Room)
Person(s) Involved
Name
Position (Student/Staff/Other)
Contact Information
Incident Details
Chemical(s) Involved
Describe the Incident
Symptoms Noted
Response & Actions Taken
Actions Taken (First Aid, Medical Attention, etc.)
Witness(es)
Reported To (Supervisor, Safety Officer, etc.)
Follow-Up
Recommendations/Preventive Measures
Signature
Date Submitted