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Laboratory Accident Reporting Form

This form must be completed in the event of a laboratory accident, fire, explosion, chemical, biological, or radiological spill, regardless of whether an injury occurred. It may be completed by the person affected by the incident, a witness, or the laboratory supervisor or manager. This form should take less than 5 minutes to complete.

In the event of an injury or illness, the Workers’ Compensation forms must also be completed if you are an employee of the University (e.g., paid by the University System of New Hampshire).

Please complete the following questions relating to the incident:

* = Required field.

1. On what date did the incident occur?*	Month Day Year
2. At what time, approximately, did the incident occur?*	AM PM
3. In which building did the incident occur?*
4. In which room did this incident occur?*
5. What is/are the name(s) of the injured person(s)?*
6. Was medical treatment sought?*	Yes No
7. If yes, where:
8. How would you describe the nature of the incident (you may choose more than one by holding down the Control key)?*
9. Who is the manager or supervisor of the laboratory?*
10. Was the person listed in Question #9 person notified of the incident?	Yes No
11. Describe the events leading to the incident. Include a description of all pertinent details such as materials used, reactions, reaction setups, etc.
12. What personal protective equipment was being worn at the time of the incident?	Safety glasses Safety goggles Side shields (with safety glasses) Faceshield Nitrile gloves Latex gloves Neoprene gloves Half or full-face respirator HEPA respirator (e.g., N-95) Dust mask Don't know None Other personal protective equipment (please list):
13. What engineering controls were being used?	Biological safety cabinet Fume hood Canopy duct Elephant trunk Don't know None Other engineering controls (please list):
14. What specific laboratory safety references (e.g., MSDS, science textbooks) were consulted prior to work with the substances involved in the incident?
15. How did you respond to the incident?
16. What steps will be taken to prevent or minimize the chance of the incident from occurring in the future?*
17. What is your name (the person completing this form)?*
18. What is your telephone number (where we may reach you to discuss this incident)?*
19. With which department are you affiliated?

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OEHS Directory

Laboratory Accident Reporting Form