Laboratory Incident Report Form

This form is used by the departmental safety committee to evaluate and identify risks, hazards, or systems and procedures that contributed to incidents that occurred in laboratories across the department. Lessons learned from such incidents will promote safety awareness at UCA teaching and research laboratories.

A incident is an event in the laboratory that resulted in serious personal injury, illness, damage to buildings or equipment, or the discharge of a fire extinguisher. Incidents can also involve chemical spills or release of potentially toxic vapors or chemicals (i.e. mercury spills).

All incidents are to be reported within 24 hrs. All paper forms are to be submitted to the Chemical Hygiene Officer or Lab Coordinator.

Date of Incident * / MM / DD YYYY
Time of Incident * : HH MM AM/PM
Location of Incident *
Course: *
Reported By: *
UCA Email:
Faculty Member *
Experiment *
Incident Type

Check all that apply.
Injury: Cut Chemical Burn Burn Chemical Exposure
Fire: Electrical Fire Solvent Metal Paper/Wood
Chemical Exposure/Spill: Spill Compromised Container Leak Vapor Liquid Solid
Illness (symptoms): Fainting Nausea Dizziness
Other: Unsafe Conditions- performing experiments under incorrect procedural/experimental set-ups/conditions. Unsafe Equipment- Equipment malfunctions or using semi-functioning equipment (hot/stir plates with melted/frayed cords, etc). Unsafe Act- Not properly following lab safety protocols (no goggles, improper attire or PPE, not following experiment procedure/set-up, etc). Events where safety equipment/barrier was challenged or failed.
Provide a full description of the incident. Include the factors that contributed to or lead to the incident. *
Materials/chemicals involved in the incident: *
If the incident resulted in serious personal injury, illness, damage to buildings or equipment, a chemical spill, or the discharge of a fire extinguisher, please complete the necessary information below.

Personal Injury or Illness
Name of injured/ill person:
Describe the injury/illness:
First Aid Given By:
Treatment of injury/illness:
Was person sent to health center or emergency room? If yes, accompanied by who?
Was person hospitalized? If yes, accompanied by who?
Fire
Source of fire:
Was the fire department called? Yes No
Was a fire extinguisher used? If yes: names of person(s) involved, number and type of extinguishers used, and location of used extinguishers.
Chemical Exposure, Spills, and Other
Chemicals Involved:
Amounts Involved:
Was a spill kit used? If yes, what type?
Describe the cause of the incident:
Describe the damage caused by the incident:

Laboratory Incident Report Form

Laboratory Incident Report Form

Incident Type

Check all that apply.

If the incident resulted in serious personal injury, illness, damage to buildings or equipment, a chemical spill, or the discharge of a fire extinguisher, please complete the necessary information below.

Personal Injury or Illness

Fire

Chemical Exposure, Spills, and Other

Laboratory Incident Report Form