Incident Report • CampusOptics

When an event occurs that causes harm to people or property, the information gleaned from the unintended outcomes should be used to help prevent future incidents. When a student is harmed in a laboratory incident, this must be reported to the supervising department and the Environmental Health and Safety (EHS) Department.

Faculty sponsors and/or instructors are required to immediately respond to a student's injury, illness, or exposure to a hazard. They must investigate, document, and report the circumstances using this form within 3 day.

The EHS Department can be reached at 594-7280 when prompt notification and requests for assistance are needed.

Reporter Info

Email* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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PART I - General Information

Does this incident involve:* Required

Injury
Illness
Exposure to a hazard (ex. bloodborne pathogen, hazardous material)

PART II – Description of Incident (What Happened?)

Incident Date and Time:* Required

Department Sponsoring the Activity:* Required

Student Name* Required

Student Email Address* Required

Faculty/Sponsor's Name* Required

Faculty/Sponsor's Job Title* Required

Faculty/Sponsor's Email Address* Required

Faculty/Sponsor's Work Phone Number * Required

Faculty/Sponsor's Cell Phone Number

Who was supervising the activity during which the incident occurred (include name and phone numbers)?

Please describe what happened. (Include factors leading up to the event, what took place, what activity or task was being performed, who was involved. Please be as specific as possible.)* Required

Was an emergency medical response (ambulance) or treatment in an emergency room needed for this incident?* Required

If yes above, please describe emergency medical response:

For non-emergency situations, does the individual plan to seek medical care?* Required

Was there any property damage?* Required

If yes above, please describe property damage:

Were safety controls (e.g. safety glasses, gloves, hard hat) required? * Required

Were safety controls provided?

Were safety controls used?

Please describe above selected safety controls used:

Were there any witnesses, if so who (include names and phone numbers)?* Required

Who was the incident reported to (include name and phone numbers)?

PART III – Incident Investigation Information

Do you have any additional information about the incident? If so please indicate:

What factors contributed to the incident?* Required

After investigating the incident, what do you determine to be the immediate cause of the incident?* Required

What did you determine to be the underlying (root) cause of the incident?

What have you done or what do you recommend to prevent a recurrence of a similar incident?* Required

Is training required for the task being performed when the incident occurred?* Required

If yes, please indicate the required training:

If yes, when was this training completed? Date:

Is retraining needed?

If so please indicate the recommendation: (documentation of retraining should be forwarded to the EHS Department):

Add Supporting Documents

Add files to upload as supporting documentation along with your incident report.

Reporter Info

Location

PART I - General Information More information

PART II – Description of Incident (What Happened?) More information

PART III – Incident Investigation Information More information

Add Supporting Documents

PART I - General Information

PART II – Description of Incident (What Happened?)

PART III – Incident Investigation Information