Department of Chemistry | Columbian College of Arts & Sciences site logo

Department of Chemistry

Columbian College of Arts & Sciences

Incident Report Form

This report is for personal injuries, accidents and near-miss events that occurred within the Department of Chemistry or during department-sponsored activities. A "near miss" is defined as an incident in which a worker might have been hurt if the circumstances had been slightly different. For example: a chemical reaction boils out of control inside of a fume hood or a worker reaches into a drawer and finds an uncapped syringe. Reporting near-miss events is strongly encouraged.

You will receive an email confirmation of your submission. If you do not receive an email, please contact Dr. Kris Noble at [email protected].

Your Status
Would you like to add an additional recipient?
Also list the names of any other persons who were involved in the incident.
Check any that occurred
If there was a fire, check all that apply:
If there was an injury or illness, check all that apply:
If there was a chemical exposure, check all that apply:
Select any safety equipment that was in use before the incident occurred
Select any safety equipment that was used to remediate the incident
Start with conditions before the incident, what happened during the incident and subsequent remediation. Provide any comments that you think will be useful to help prevent this type of incident from happening again.
Do you feel that you were adequately equipped, trained and prepared for such an incident?
Did you seek medical attention?
If you received medical treatment, is a follow-up required?
Did you notify Environmental Health & Safety (EHS)?
Check any emergency services that were received or requested
(Ambulance, hospital, primary care physician, etc.)
Maximum 6 files.
256 MB limit.
Allowed types: gif, jpg, jpeg, png.
CAPTCHA