| This is the
information you submitted. It is recommended that you print
and file the printed copy in your records |
| Incident date: incidentdate |
|
bldgroom |
Major Professor/supervisor:
|
supervisor |
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, include them:
whathappened |
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?
InjuryDamage |
Q3. What should/must be done to learn from and prevent this from happening again?
prevention |
Q4. Have there been any requests for services
-- repairs, fire extinguisher replacement, room ventilation
balancing, exposure monitoring....?
requests |
Q5. 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:
meeting |
|