Laboratory/Studio and Field Incident Report Form

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Laboratory/Studio and Field Incident Report Form

The Laboratory/Studio and Field Incident Report form is to be completed by the Lab Manager/Teaching Assistant/Instructor for any incident that occurs in any University of South Florida affiliated teaching or research laboratory/studio or field research project. An incident means any unplanned event within the scope of a procedure that causes, or has the potential to cause, an injury or illness and/or damage to equipment, buildings, or the natural environment.

If an accident or incident resulted in a work-related injury or illness, your supervisor must be contacted immediately. Please proceed to the Worker's Compensation website, http://usfweb2.usf.edu/hr/workerscomp/, for more information on how to report a work-related injury or illnes

Please fill out the online Laboratory/Studio and Field Incident Report form below and submit to Environmental Health & Safety within 24 hours of the incident. Due to medical privacy concerns, no personal identifying information of the person involved in the incident shall be entered or submitted with the form.

* Required fields

Select one that pertains to your incident:

If 'Other', please indicate:

Date of Incident

Time of Incident

Location of Incident

Preparer's Name

Department/Division

College

Phone Number

Email Address

(1) Incident Description

Describe the circumstances of the incident:

(2) Injury/Illness/Damage to Equipment, Building, Environment

Describe the extent of injuries and/or damage. Exactly where on the body did the injury occur?

(3) Actions Taken: Response/Treatment/Cleanup

Describe the nature of the emergency action taken:

Did the person seek medical treatment? Indicate Yes or No, and explain:

Were emergency personnel contacted?

If you selected 'Yes' above, please choose all that apply:

USF Environmental Health & Safety Office

Fire

Hazmat

Police

Medical

(4) Corrective Action Taken

Corrective action taken by Preparer:

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