Departmental Incident Report Form - The State Of Ohio printable pdf download

The Ohio State University Department of Chemistry Incident Report Form (9/03)

___________________________________________________________________________________________________________________________________________________________________

Date of Incident:______/______/______ Time of Incident:____________ AM or PM

Name (of Injured):______________________________________ University ID# (optional):________________

Address:_________________________________________________________ Phone_____________________

City & State:_________________________________ Age:______ Sex:_______

________________________________________________________________________________________________________________________________________________________

Position (Check One): Undergraduate:______ Graduate Student:______ Faculty:_______ Post-Doc:______ Staff:______

Visitor:_____ Other:____________________________

Location of Incident: Building__________________________ Room Number:_____________

Type of Incident: Fire:_____ Chemical Spill:______ Medical Injury:_______ Other:_________________

Incident Occurred During: Lab Course: (Course Number and experiment #):__________________________________________

Research:_____ Other:______________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________

Was the University Police called or was 911 called ? _______________ (if yes, circle which was called)

If injury, was the victim given treatment by emergency personnel?_____________________________________________________

If injury, was the victim transported by emergency personnel?___________ or

Did the victim refuse treatment or transport by emergency personnel?________________

___________________________________________________________________________________________________________________________________________________________________

Type of Injury (check all that apply): Thermal Burn________ Chemical Burn_______ Glass Cut, Scrape, or Puncture_______

Non-Glass Cut, Scrape, or Puncture_______ Chemical Irritation of Skin________ Irritation of Eyes_______

Inhalation of Fumes______ Other______________________________________________________________________________

Was the victim wearing personal protective equipment? (goggles, etc., please specify) ___________________________________

___________________________________________________________________________________________________________________________________________________________________

Description of Incident (Use the back of this form if necessary):

THE UNDERGRADUATE STUDENT HAS THE RIGHT TO REFUSE MEDICAL TREATMENT AND/OR EMERGENCY

TRANSPORT. MEDICAL TREATMENT CAN BE SUGGESTED BUT NOT ENCOURAGED. THE CHEMISTRY

DEPARTMENT CANNOT BE HELD RESPONSIBLE, FINANCIALLY OR OTHERWISE, FOR MEDICAL TREATMENT

INCURRED BY THE STUDENT.

Teaching Asst Signature (if a lab course):_____________________________________________________________

Lab Supervisor Signature:_________________________________________________________________________

Name and Phone of Witness if available: