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Chemistry Department Incident Report
Please fill this form out in addition to reporting a Safety Concern/Near Miss or Injury/Incident to the University.
https://rmi/colostate/edu/incident-reporting/
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Name
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Your answer
Email
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Your answer
List the name and telephone number of the person(s) injured:
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Your answer
List the name, email address, and telephone number of all witnesses, if any:
Your answer
Incident location (building, room #, etc.)
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Your answer
If the incident occurred in a research group, list the name of the PI:
Your answer
Date and time of the incident:
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Your answer
Describe briefly, but sequentially, all the known facts concerning events leading up to and following the incident. These facts may be established with participants or witnesses. Avoid opinion and conclusions:
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Your answer
If the incident resulted in injury, describe briefly the nature and extent of the injury, the type of first aid rendered and by whom, whether or not an ambulance was called and used, and the time involved. Also indicate the condition of the injured after treatment:
Your answer
If the incident resulted in a fire, how was the fire extinguished, was the fire alarm sounded, was the fire department called, how soon did the fire department arrive, and if hand fire extinguisher were used, were they submitted for refill?
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Show a copy of this completed report to your supervisor.
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