Instructions for Incident Report Form Completion
Each section of the form should be completed and signed by the
indicated p
persons. The form must be filled out in the p
presence of the
responding personnel in either the laboratory or in room 104. See the
form for specific information to be included in each section.
After completion, the form will be submitted to the department staff in
room 104 by the responding personnel, and then a copy must be given to
the injured
j
student. If no one is available in room 104,, see chemistry
y
stockroom personnel in room 117.
To be completed and
signed by the person
injured.
To be completed and
signed by the supervisor
(teaching assistant).
To be completed
p
and
signed by the safety
coordinator/responding
personnel.
806-742-3067
Prof. Carol Korzeniewski
Incident Report Form
(for reporting incidents in instructional and research laboratories)
The following section is to be completed by the Person Injured or Involved in the Incident:
Last Name:
First Name:
Sex:
Date of Birth: (MM/DD/YY)
F
Part of Body Involved:
Date of Incident: (MM/DD/YY)
Time of Incident:
a.m.
Location of incident (room #):
M
p.m.
Location of incident (in the room):
Person Injured/Involved in Incident’s Contact Information:
Thoroughly describe what happened (cause of incident, type of first aid administered, etc.):
Laboratory first aid was administered at the time of the incident:
Further medical attention was offered:
Yes
No
Yes
No
If yes, this attention was:
Accepted
Rejected
Signature of Person Injured or Involved in the Incident:
The following section is to be completed by the Supervisor or Teaching Assistant:
Last Name:
First Name:
Was a safety rule violated?
Yes
Department:
If yes, explain:
Supervisor’s Contact Information:
No
Thoroughly describe what happened (cause of incident, location – room number and location in the laboratory, actions taken in response to the situation,
etc.):
Lab Director was notified by the Supervisor (Teaching Assistant):
Yes
No
Signature of Supervisor or Teaching Assistant:
The following section is to be completed by the Safety Coordinator/Responding Personnel:
Last Name:
First Name:
Date Reported: (MM/DD/YY)
Contact Information:
Safety Coordinator’s/Responding Personnel’s Actions:
Signature of Safety Coordinator/Responding Personnel:
Department Phone Number:
Point of Contact:
Please send this form to Environmental Health & Safety at Mailstop 1090, Room 122,
Administrative Support Center.
EH&S Form OSH-18, 2 April 1999; Revised for Instructional and Research Laboratories, 19 January 2012