University of Colorado Denver |Anschutz Medical Campus
Institutional Biosafety Committee
Incident Report Form
All University employees, staff and students are required to report all potential exposures to or releases of rDNA, microorganisms or biological
toxins within 24 hours of an event; and all exposures to human blood and bodily fluids in the research setting. Potential exposures include:
needlesticks; other sharps injuries; bites of animals known or suspected to be infected; spills and splashes of these materials, in or out of
containment which may result in an inhalation or other contact exposure; any releases of rDNA, microorganisms or biological toxins to the
environment (e.g. sanitary sewer system, exhaust ventilation systems). Unauthorized releases of transgenic animals or plants or their tissues must
also be reported using this form.
Complete and return to the Institutional Biosafety Committee via email to the attention of the Biosafety Office
(biosafety.program@ucdenver.edu) Alternatively, it may be submitted by fax 303-724-0388 or by campus mail Attn: Biosafety Office, Mailstop
F484. Questions should be directed to the Biosafety Office, 303-724-0345.
All personnel exposures must also be reported to University Risk Management, by completing the appropriate Workers Compensation Claim
form, available on the web at: https://www.cu.edu/content/fileclaim Questions regarding WC should be directed to URM, 303-724-1127.
Does this incident involve recombinant DNA research subject to
theNIH Guidelines ?
Injured/Exposed Individual (Name), Job Title

Office or laboratory telephone
Email Address
Laboratory Biosafety Level
BSL1
BSL2
ABSL1
ABSL2
Individual Reporting (Name and Job Title)
YES
OBA)
NO (If no, this incident does not have to be reported to
Date of report:
BSL3
ABSL3
Date of incident:
Name of Principal Investigator or supervisor
Office or laboratory telephone
PI or Supervisor Email Address
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YES  NO
NIH grant or contract number:
Is this an NIH funded project?
If yes, provide:
NIH funding institute or center:
NIH program officer contact information (name, email etc):

What was the nature of incident? Check all that
apply






Has a report of this incident been made to the PI
or Supervisor?
Personnel exposure:
Needlestick or sharps injury
Animal bite or scratch
Spill within containment
Loss of containment or spill outside of containment
Loss of transgenic animal
Failure to obtain IBC approval
Failure to follow approved containment conditions
Other - please describe:
Microorganisms involved:
Recombinant
Non-Recombinant
Toxin involved:
Cell lines or strains involved: :
Splash exposure
PI or supervisor notified
University Risk Management notified
To University Risk Management Workers
Compensation Program?
Medical care sought or initiated.
Health Care Provider consulted
Was medical care sought or initiated?
If so please indicate by checking the appropriate
box.
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rev 3 July 2012
Please provide a complete narrative of the incident including a timeline of events. The incident should be described in sufficient detail to allow for
an understanding of the nature and consequences of the incident. Include the following information as applicable.

Who was involved in the incident, including others present at the time of the incident?

Describe completely the recombinant agent or material or other agents in use.

For recombinant DNA materials: What genes have been introduced into the material: include toxins, antibiotic resistance genes,
oncogenes or proto-oncogenes, or other changes that may affect risks and treatment?

The incident location (e.g. laboratory building & room number; vivarium; non-laboratory space).

Actions taken immediately following the incident/violation, and by whom, to limit any health or environmental consequences of the event.

Indicate if there was a laboratory standard operating procedure (SOP) in place for the research or experimental procedure being conducted.
Indicate if there was any deviation from these SOPs at the time of the incident.

Indicate all the personal protective equipment in use at the time of the incident.

Indicates any medical advice/treatment/surveillance provided or recommended after the incident, with medical surveillance (test) results. If
test results are not available at the time of initial report please indicate when results will be available.

Any injury or illness associated with the incident.

Equipment failures that occurred or contributed to the incident.
DESCRIPTION OF INCIDENT AND RESPONSE MEASURES: (use additional space as necessary)
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