Details of Incident:
[Nature of incident, e.g., illness, accident, injury. If injury occurred,
indicate circumstances and who was involved. Indicate any substances
(e.g., amount and kind of chemical) or object involved.]
What action was taken:
(e.g., indicate if security or the nurse was contacted and if transport
to hospital occurred.)
What can be done to prevent
recurrences:
Investigated by: ________________________________________
(Print Name)
____________________________________________________
(Signature)
____________________________________________________
(Date)
When
completed, return form to the Environmental Health and Radiation Safety
(EHRS) Department, Box #85 or Griffith Hall room #300, #325.
*Existing
procedures must still be followed; i.e., calling Public Safety or
completing accident reports.
