Appendix E

LABORATORY ACCIDENT REPORT FORM

This form is to be filled out by the responsible faculty member and filed with the Department Chemical Hygeine Officer and the Office of Student Health Services.

Name:_____________________________________Date:_____________________

Social Security #:____________________________Student?Staff?or Faculty?___

Department:________________________________Date/Time of Incident:______

Campus Address:____________________________Campus Telephone:________

Home(Local) Address:_________________________HomePhone#:____________

Location of accident:___________________________________________________

Cause of Injury:______________________________________________________

Type of Injury:_______________________________________________________

Medical Facility:______________________________Ambulance Needed: Y N

Physician:_______________________________

Witnesses: Name Address Phone #

________________________ ____________________ ____________

________________________ ____________________ ____________

Brief description of incident (include the use of personal protective equipment, fume hood, safety shower and/or fire extinguisher): Use back side of form for extra space....

Name of Faculty Member :____________________

Signature of Faculty Member:______________________________