Incident Report Form
For reporting incidents occurring at the FM Core Facilities
DO NOT use this form to report injury, immediate life threatening issue or death of a
person. There is a safety incident report online for the above cases or call Environmental
Health Safety & Risk Management department at 2360 or Emergency department 6600
or 6631.
Name:
Department:
Position:
PI:
Date of Incident:
Time:
Category of Incident
Biological Spill
Reservation issues
Biohazardous bags
Stuff missing
Reagents missing
Equipment Failure
Water spill
Liquid Nitrogen

Specific area where the incident happen:

Complete description of the cause of Incident (Please provide as much details as possible):

Suggested Corrective measures to prevent similar incidents:
Completed By:
Signature:
Core Facility Supervisor:
Signature: