Laboratory Accident Incident Report Form
Date of Report
Name of Person Reporting
Contact Information
Laboratory Name/Location
Date of Incident
Time of Incident
Type of Incident
Chemical Spill
Fire
Biological Exposure
Equipment Failure
Injury
Other
Description of Incident
Immediate Actions Taken
Names of Witnesses
Injuries Sustained (if any)
Reported To (Supervisor/Safety Officer)
Recommendations/Preventive Measures