UNIVERSITY OF CALIFORNIA AT LOS ANGELES
BERKELEY • DAVIS • IRVINE • LOS ANGELES • RIVERSIDE • SAN DIEGO • SAN FRANCISCO
UCLA
SANTA BARBARA • SANTA CRUZ
Mandatory Accident Report Form
UCLA Microfabrication Laboratory Please fill out this form completely whenever an accident occurs in the UCLA Microfabrication Laboratory First Name: Student/Employee ID: Email Address: User Information Last Name: Telephone number: Advisor/Professor’s Name:
Hazards Identification (Multiple Items may be chosen) Electrical Problem: Lab Equipment Problem: Chemical Spill: Fire or Smoke: Flammable Chemicals: Broken Glass: Earthquake Event: Toxic Gas Leak: Misused Chemicals: Personal Injury: Others Doctor Visits (Multiple Items may be chosen) Emergency Room Visit: Hospitalization: Lab First Aid Kit: Went Home, No Doctor Required: No First Aid Required: No Injury: Others: EHS (Multiple Items may be chosen) Did Not Call EHS: Called EHS: Did Not Call Microlab Office: Call Microlab Office: Others: Important Telephone Numbers Contact Telephone Extension Fire, Police, Ambulance x911 (university help) Hazardous Materials Spills x56945 Environment, Health and Safety (EHS) x51229 Nanolab Office x68923 Microlab Office x54593 Telephone Number 911 (City Police) 825-6945 825-1229 206-8923 825-4593
Date of Accident: Time of Accident: Accident Description (Please describe how the accident occurred):
Accident Resolution (Please describe how the accident was resolved):
Accident Follow-Up Required by Microlab Staff (To the best of your information, what still needs to be done? How did you leave the accident event?)
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