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 ______________________________________________________
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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 ______________________________________________________