LABORATORY INCIDENT REPORT FORM
CONTACT SECURITY IN CASE OF SERIOUS INJURY
INSTRUCTOR:
LAB ROOM:
DATE AND TIME OF INCIDENT:
DESCRIPTION OF INCIDENT (ATTACH ADDITIONAL PAGES IF NEEDED)
SIGN AND SUBMIT REPORT TO LABORATORY SUPERVISOR OR DEPARTMENT CHAIR.
COPY OF THIS FORM IS TO BE SUBMITTED TO CHEMICAL HYGIENE OFFICER.
SIGNATURE___________________________
DATE__________________
RECEIVED BY__________________________
DATE OF RECEIPT__________
____STUDENT WAS OFFERED AND REFUSED AID BY SECURITY
STUDENT SIGNATURE____________________________
DATE__________________