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.