Incident Report | Environmental Health and Safety

Incident Report

Building

Room Number/Area Description *

First Name *

Last Name *

Phone Number *

Email *

Affiliation *

Supervisor Name *

Supervisor Email *

Was Anyone Injured *

Yes

Describe the Injury

First Name *

Last Name *

Phone Number *

Email Address *

Did the injured receive medical care? *

Yes

Where? *

Please describe what happened *

Were safety measures (PPE, SOPs, etc.) in place? *

Yes

Describe the safety measures that were taken *

Were the safety measures followed? *

Yes

Incident Details (How did it happen? What tools equipment were in use, timeline, were photos taken? (please attach photos), etc.): *

Corrective Actions (What can be done to prevent this in the future): *

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