THE UNIVERSITY OF AKRON
ENVIRONMENTAL AND OCCCUPATIONAL HEALTH AND SAFETY
ACCIDENT REPORT FORM
TIME
Date:
Time:
Ext:
AND
Dept:
Building:
Room:
PLACE
Person Reporting Accident:
HAZARDOUS
SUBSTANCES
INVOLVED
CAUSE OF THE
ACCIDENT
EXTENT OF
DAMAGE AND
INJURY
STATUS OF
EXISTING
CONDITIONS
Spill on Bench:
Spill on Floor:
Where did the injury occur:
What happened:
Was there an unsafe situation when the accident occurred?
What was it:
Name:
INJURED PARTY
SSN:
Home Phone:
Transport to:
Hospital
Health Services
I (signed) __________________ refused to receive medical assistance
WASTE
CLEANUP
Was the hazardous waste managed:
By:
FOLLOW-UP
DATE
ADDITIONAL
INFORMATION
COPY TO:
Prepared By: