Employee           Student           Graduate Student           Visitor
Name:  (Laboratory Supervisor/Principal Investigator)
Department
Time of Incident
Location of Incident
Date of Incident

Details of Incident:  [Also include, what happened and how and why the incident occurred, the injury or illness, chemical, substance or object involved, and amount/volume.]

What action was taken: (What was done to protect individuals or clean up substance. Also indicate if Public Safety or the nurse was contacted and if transport to hospital occurred.)

Call Facilities Services for injuries that require blood/body fluid clean-up. Secure and isolate the area.

What can be done to prevent recurrences:(e.g, SOP's developed, re-training, safety equipment and PPE, counseling)

Investigated by (Laboratory Supervisor/Principal Investigator):

(Print Name)

(Signature)

(Date)

When  completed, return form to the Environmental Health and Radiation Safety (EHRS) Department, Box #85.
*Existing procedures must still be followed;  i.e., Supervisors completing Human Resource's Accident Investigation Report for employees.