USF Incident Report
Use this form for a Laboratory Injury / Accident / Near Miss / Chemical or Biological Spill.

Instructions:  This form must be completed by the Instructor or Teaching Assistant assigned to any undergraduate laboratory or graduate laboratory in which an incident occurs. The completed form will be forwarded automatically to the Lab Safety Manager (Craig Conforti).
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Email *
Name of Injured individual (First / Last / Middle Initial)
Phone number of Injured / Involved individual:
Email of Injured / Involved individual:
Course # or Research Group:
Date of the Incident:
MM
/
DD
/
YYYY
Time of the Incident:
Time
:
Brief description including how the incident occurred and any specific injury, which resulted from the incident:
List any chemicals or biological organisms involved:
List any equipment involved:
Was the individual wearing safety glasses?
Clear selection
Indicate any other safety equipment (gloves, face shield, etc.) that the individual was wearing:
Was the eyewash and / or safety shower used?  
Clear selection
If the eyewash and / or safety shower was used, how long did the individual flush the affected area of the body?
List the names of the witnesses to the incident:
List specific suggestions regarding how to prevent similar incidents in the future:
Was First Aid administered?
Clear selection
If First aid was administered, who administered the first aid and what was done:
Was 2-911, (415) 422-2911, or 911 called for assistance?
Clear selection
Was the individual transported to the hospital?
Clear selection
If yes, which hospital?
Indicate how the individual was transported:
Indicate who accompanied the individual:
Your Name:
Your Title:
Clear selection
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