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MI-HQ Lab Incident and Near-Miss Report
Author of Report *
Date of report *
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Email address *
Company Name *
Date of Incident *
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TIme of Incident *
Time
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Personnel Involved *
Principal Investigator (or Lab Director) *
Location of Incident *
What happened? Please describe in detail the lab process, chemicals, and activities involved in the incident. *
Describe any and the amounts of hazardous chemicals or materials involved. *
Describe any and the amounts of non-hazardous chemicals or materials involved. *
Where did you dispose of these chemicals or materials? What was your method of cleanup? *
Is there a written SOP for the procedure being performed? *
Describe any injuries. *
Did anyone seek medical treatment as a result of this incident? Where? *
Please describe any damage to the building. *
Please describe any damage to equipment. *
Why did it happen? Be specific in describing unsafe acts or conditions that contributed to the cause of the incident. *
What corrective actions have already been implemented to prevent a recurrence? *
What corrective actions have already been implemented to prevent a recurrence? *
What corrective actions have been identified that still need to be implemented? Describe any obstacles preventing the implementation of identified corrective actions. *
Were any items from Spill Kit or First Aid Kit needed? *
*
What was your method used for cleanup? *
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