Incident Report Form
For apparently non-serious injuries or exposures:
contact lab supervisor, and Dr. Finster (Chemistry, 6441)
For any injury or exposure which may seem serious or life-threatening,
first: call 9-911 immediately with detailed information on the location of patient(s)
next: call 6363 to notify University Security
next: contact Dr. Finster (Chemistry)
next: locate hard copy of relevant MSDS(s)
Describe incident/accident:
If Injuries or Exposures: (one sheet for each patient)
Name of patient: _______________________________ Age: ________
Current medications: _______________________________
Medical history: _______________________________
Known allergies ______________________
Date: _________ Time of injury/exposure: ____________
Best Estimate of Exposure:
Substance(s): _______________________________________________
Duration and route of exposure: _______________________________________________________
(Inhalation, ingestion, injection, absorption)
NOTE: Transfer relevant MSDS(s) to emergency room or physician with patient.
Signs and Symptoms
Symptoms reported by patient
Signs of injury and/or exposure as reported by bystanders:
Actions taken on scene:
Emergency Room Personnel: Please make a copy of this form for your records, if necessary, and return the original to: Human Resources, Wittenberg University, P.O. Box 720, Springfield, OH 45501.
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