LABORATORY INCIDENT REPORT FORM - PDF - PDF

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					          LABORATORY INCIDENT REPORT FORM

Date of Report: __________

Name of Individual filing the report:__________________________________________

Name of Individual (s) involved in the incident:_________________________________

Time and Place of incident:
_________________________________________________

Description of the incident:




Description of the injury / property damage:




Description of safety instructions given prior to the incident:




Description of follow-up action, including medical attention and clean-up, if applicable:




Signature of Faculty Member / Supervisor: ___________________________________

Signature of Student / Employee:
____________________________________________




Department of Laboratory Resources and Safety   Centre College   600 W Walnut St   Danville KY 40422