Lab Accident/Injury Reporting Form

Name Email Phone Department Date of Incident Time of Incident Location (Lab/Room#) Describe what happened Type of Incident Injury Chemical Spill Fire Equipment Failure Other Possible cause(s) of accident/injury Name(s) Affiliation (Student/Staff/Faculty/Visitor) Describe the injury Did the injured person(s) receive medical attention? Yes No If yes, please specify Corrective/Preventive actions taken or planned Date Reported Signature