Public Safety Building, 4 th
Floor
3412 Forbes Ave
Pittsburgh, PA 15260
Phone: (412) 624-9505
Fax: (412) 624-8524 www.ehs.pitt.edu
TYPE OF INCIDENT : Accident____ Hazardous Material Spill/Release____ Fire _____ Other ____________
THIS REPORT INVOLVES A : Student ____Faculty ____ Staff____ Visitor____ General Public __________
INDIVIDUAL ASSIGNED TO:
___Pittsburgh ___ Johnstown ___Greensburg ___Bradford ___Titusville ___Pymatuning ___Plum ___ RIDC
___Off Campus
Complete this form for any; accident resulting in personal injury, incident that may have resulted in injury, or property damage that occurs on University property or any University sponsored event on or off campus. The University staff/faculty person in charge of the department or event is responsible to assure that this form is completed.
ACCIDENT / INCIDENT INFORMATION
INJURED’S NAME (please print):___________________________________________________________
ADDRESS: ____________________________________________________________________________
PHONE: ______/______/_______
DATE OF ACCIDENT/INCIDENT: ______/_____/______. TIME OF DAY: _________AM / PM
WHERE DID THE ACCIDENT / INCIDENT OCCUR?
Building ____________________Floor_______ Room______ Campus Grounds______________________
Event _________________________________________________________________________________
DESCRIBE THE ACCIDENT / INJURY / INCIDENT: ( Describe clearly what took place. Include the materials, vehicles, equipment, processes, buildings and people involved.)
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MEDICAL TREATMENT AND PROVIDER: (for accident only)
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IF A SPILL/RELEASE WAS INVOLVED: Chemical___ Biological___ Radioactive___
Chemical or biological agent name(s): _______________________________________________________
Approximate quantity: ____________________________________________________________________
Did spill reach a floor drain or storm sewer? ___________________________________________________
Who remediated the spill/release? ___________________________________________________________
Method of clean-up: ______________________________________________________________________
Was a Hazardous waste generated by clean up activities? ________________________________________
Who was notified? _______________________________________________________________________

IF A FIRE WAS INVOLVED:
Who discovered? _________________________________________________________________________
Materials involved: ________________________________________________________________________
Source of Ignition: _________________________________________________________________________
Who extinguished ( Instructor, Student, Police, Fire Department…)? __________________________________________________
Extinguishing mechanism ( fire extinguisher, sprinkler system, fire hose… ): __________________________________
Was fire alarm system activated? _____________________________________________________________
Extent of damage: _________________________________________________________________________
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IMMEDIATE CAUSES :
(Actions/conditions that contributed most directly to this accident/incident.)
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HAZARD CONTROL :
(What action has been or will be taken to correct the hazardous acts or conditions causing this loss?)
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Report Completed By : ___________________________________________ DATE____/____/____
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