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Lab Incident and Injury Report

Laboratory Incident and Injury Report

Supervisors are to complete this form for any incident or injury in the lab. Complete only those parts perinate to the event.

Person Reporting(Required)
MM slash DD slash YYYY
Time(Required)
:
Type of Incident(Required)
Was medical treatment necessary?(Required)
Was medical treatment or assessment performed by a physician or healthcare worker?(Required)
If YES, and the individual is an employee, graduate student, or student employee, report it to Human Resources by emailing or by phone at 336.758.4700, Ext. 3.

Biological Exposures

Needle Stick and/or Blood and Other Potentially Infectious Material (OPIM) Exposure
Microbiological Exposure
Animal Exposure

Chemical Exposures

Type of Exposure

Other Injury

Incident Without Injury

Type of Incident
Was there damage to equipment or building materials?
If YES, contact Facilities at 336-758-4255 to report damage.

Fire

Was fire alarm pulled?
Was fire extinguisher used?
If YES, call Facilities at 336-758-4255 for replacement.

Flood / Water Intrusion

Has the cause of the flood been identified?
Was the flood contained to the room?
Was any electrical equipment affected by the flood?
If YES, contact Facilities for an electrical inspection prior to using equipment. (336) 758-3427.

Mechanical

Was the mechanical incident building related?
If YES, contact Facilities inspection. (336) 758-3427.

Spills and Releases

Type of Spill or Release
Was spill contained to the room?
Do waste materials from spill clean up need to be removed?
If YES, call Environmental Health and Safety at 336-758-3427

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