Incident Report  For Department of Chemistry use.  Please complete every field:

Incident date:

Building and room:

Major Professor/supervisor:

Person completing form:

Your email:

Q1. What exactly happened?  Include all known details, causes and results, names of all persons involved and times.  If details of a chemical reaction or process are pertinent, please include them:
 
Q2. Was there injury, illness, or property damage of any type that is known or thought to have been a result of this incident?  Was anyone seen by a medical care provider as a result of the incident?
 
Q3. What should/must be done to (try to) prevent this from happening again?  
Q4. Does the group or individual or supervisor wish to have a meeting/discussion/training session with the safety person?  Comment and suggest dates/times if so: