Department:                                                                                               Report Date:

Name:

Social Security Number:

Date of Incident:

Time of Incident:

Location of Incident:

Instructor's Name:

Witnesses (Name / SS# / Position (Student/Faculty/Staff)) :

1):

2):

3):

Brief Description of Incident:

Please Answer the Following Questions:

Was the safety shower, eye wash, or fire extinguisher required?

Was medical attention recommended?  

Was the MSDS consulted for proper treatment in the event of a chemical spill or contact?

Were the proper authorities notified (Fire and Life Saefty, campus Security, or Health Services) ?

WHAT CORRECTIVE ACTION WAS TAKEN TO INSURE THAT THIS WILL NOT HAPPEN: