"Incident Report Form - Ohio State University"

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The Ohio State University Department of Chemistry Incident Report Form (9/03)
___________________________________________________________________________________________________________________________________________________________________
Date of Incident:______/______/______ Time of Incident:____________ AM or PM
Name (of Injured):______________________________________ University ID# (optional):________________
Address:_________________________________________________________ Phone_____________________
City & State:_________________________________ Age:______ Sex:_______
________________________________________________________________________________________________________________________________________________________
Position (Check One): Undergraduate:______ Graduate Student:______ Faculty:_______ Post-Doc:______ Staff:______
Visitor:_____ Other:____________________________
Location of Incident: Building__________________________ Room Number:_____________
Type of Incident: Fire:_____ Chemical Spill:______ Medical Injury:_______ Other:_________________
Incident Occurred During: Lab Course: (Course Number and experiment #):__________________________________________
Research:_____ Other:______________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________
Was the University Police called or was 911 called ? _______________ (if yes, circle which was called)
If injury, was the victim given treatment by emergency personnel?_____________________________________________________
If injury, was the victim transported by emergency personnel?___________ or
Did the victim refuse treatment or transport by emergency personnel?________________
___________________________________________________________________________________________________________________________________________________________________
Type of Injury (check all that apply): Thermal Burn________ Chemical Burn_______ Glass Cut, Scrape, or Puncture_______
Non-Glass Cut, Scrape, or Puncture_______ Chemical Irritation of Skin________ Irritation of Eyes_______
Inhalation of Fumes______ Other______________________________________________________________________________
Was the victim wearing personal protective equipment? (goggles, etc., please specify) ___________________________________
___________________________________________________________________________________________________________________________________________________________________
Description of Incident (Use the back of this form if necessary):
THE UNDERGRADUATE STUDENT HAS THE RIGHT TO REFUSE MEDICAL TREATMENT AND/OR EMERGENCY
TRANSPORT. MEDICAL TREATMENT CAN BE SUGGESTED BUT NOT ENCOURAGED. THE CHEMISTRY
DEPARTMENT CANNOT BE HELD RESPONSIBLE, FINANCIALLY OR OTHERWISE, FOR MEDICAL TREATMENT
INCURRED BY THE STUDENT.
Teaching Asst Signature (if a lab course):_____________________________________________________________
Lab Supervisor Signature:_________________________________________________________________________
Name and Phone of Witness if available:
The Ohio State University Department of Chemistry Incident Report Form (9/03)
___________________________________________________________________________________________________________________________________________________________________
Date of Incident:______/______/______ Time of Incident:____________ AM or PM
Name (of Injured):______________________________________ University ID# (optional):________________
Address:_________________________________________________________ Phone_____________________
City & State:_________________________________ Age:______ Sex:_______
________________________________________________________________________________________________________________________________________________________
Position (Check One): Undergraduate:______ Graduate Student:______ Faculty:_______ Post-Doc:______ Staff:______
Visitor:_____ Other:____________________________
Location of Incident: Building__________________________ Room Number:_____________
Type of Incident: Fire:_____ Chemical Spill:______ Medical Injury:_______ Other:_________________
Incident Occurred During: Lab Course: (Course Number and experiment #):__________________________________________
Research:_____ Other:______________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________
Was the University Police called or was 911 called ? _______________ (if yes, circle which was called)
If injury, was the victim given treatment by emergency personnel?_____________________________________________________
If injury, was the victim transported by emergency personnel?___________ or
Did the victim refuse treatment or transport by emergency personnel?________________
___________________________________________________________________________________________________________________________________________________________________
Type of Injury (check all that apply): Thermal Burn________ Chemical Burn_______ Glass Cut, Scrape, or Puncture_______
Non-Glass Cut, Scrape, or Puncture_______ Chemical Irritation of Skin________ Irritation of Eyes_______
Inhalation of Fumes______ Other______________________________________________________________________________
Was the victim wearing personal protective equipment? (goggles, etc., please specify) ___________________________________
___________________________________________________________________________________________________________________________________________________________________
Description of Incident (Use the back of this form if necessary):
THE UNDERGRADUATE STUDENT HAS THE RIGHT TO REFUSE MEDICAL TREATMENT AND/OR EMERGENCY
TRANSPORT. MEDICAL TREATMENT CAN BE SUGGESTED BUT NOT ENCOURAGED. THE CHEMISTRY
DEPARTMENT CANNOT BE HELD RESPONSIBLE, FINANCIALLY OR OTHERWISE, FOR MEDICAL TREATMENT
INCURRED BY THE STUDENT.
Teaching Asst Signature (if a lab course):_____________________________________________________________
Lab Supervisor Signature:_________________________________________________________________________
Name and Phone of Witness if available: