Accident Report Form

Teaching laboratory Accident/Incident Report

Use this form to report injuries, accidents, fire, or other serious incidents that have occurred during a teaching laboratory. If a fire extinguisher is used, the extinguisher must be serviced.

INSTRUCTOR’S REPORT:

This page is to be filled out by the instructor after he/she interviews the students. The students must read and sign the statements below.

Date of Incident: __________________________ Time: ________________________

Course/Number: __________________________ Instructor’s Name: ________________________

Name of student(s) involved in incident

________________________________________________________________________

What was the student doing at the time the incident occurred:

________________________________________________________________________

Description of Incident, be specific: ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Where did the Incident Occur be specific?

________________________________________________________________________

Actions Taken (circle all that apply): a)First Aid (e.g., wash, burn ointment, band-aid, eyewash, shower, student sent to Health Services, ER. Provide name of accompanying person (if any) other (describe)

________________________________________________________________________

________________________________________________________________________

Will there be class time lost because of this accident? YES____ NO___

Instructor’s Signature :_____________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

INJURED STUDENT’S REPORT:

This page is to be filled out by the student. The student must read and sign the statements below.

What was the student doing at the time the incident occurred:

________________________________________________________________________

Description of Incident, be specific: ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Where did the Incident Occur be specific?

________________________________________________________________________

1. Did you attend safety training for this piece of equipment? YES____ NO___

2. Did the instructor inform you about the hazards of this piece of equipment? YES____ NO___

3. Were you wearing Personal Protective Equipment? YES____ NO____

4. Was the experiment performed with adequate ventilation? YES____ NO___

Signature of Student ______________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

WITNESSING STUDENT’S REPORT (IF APPLICABLE):

This page is to be filled out by the student. The student must read and sign the statements below.

Description of Incident, be specific: ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Where did the Incident Occur be specific?

________________________________________________________________________

1. Did you attend safety training for this piece of equipment? YES____ NO___

2. Did the instructor inform you about the hazards of this piece of equipment? YES____ NO___

3. Were you wearing Personal Protective Equipment? YES____ NO___

4. Was the experiment performed with adequate ventilation? YES____ NO___

Signature of Student ______________________________________________________