Injury: Cut Chemical Burn Burn Chemical Exposure Other-

Fire: Electrical Fire Solvent Metal Paper/Wood

Explosion/Implosion: High Pressure Low Pressure Vacuum Line Chemical
                                Equiqment Malfunction Other-

Chemical Exposure: Spill Leak Container Break Vapor Liquid Solid
                               Other-

Illness (Symptoms): Fainting Nausea Dizzy Other-

Date: Time: AM PM

Location: Room # -______ Davidson Hahn

Person(s) Involved:

Witnesses:

Services/Help Requested or Received (check):

Town Fire Department VPI Police Town Police Rescue Squad
University Safety Office Department Safety Persons Other-

Name if possible:

Safety Equipment Used for Remediation of Incident (check):

Fire Extinguisher Fire Blanket First Aid Kit Respirator Goggles Gloves
Spill Control Equipment Eye Wash Shower Neutralizing Material Hood
Other-

Safety Equipment in Use Before Incident (check):

Gloves Eye Protection Hood Glovebox Wrapped Glassware Respirators
Lab Coats Apron Other-

Description of Other Standard Safety Precautions in Use:



Description of Events - Before - During - After Incident:

Do you feel you were adequately equipped, trained, prepared for such an incident? Yes No
Comments (on any aspect of incident):

Signed: Date:

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Reviewer Use Only:

Reviewed By: Date:

Comments/Actions

Copies to EHSS - Date: