Initial Injury Illness
Incident and Near Miss Report Form
Was medical attention needed?
Author of Report
Laboratory Director or Supervisor
Lab Director/Supervisor's Email
Academic Department (Dept. of Person(s) involved, if different than Incident Dept., below.)
Additional Contact Name
Additional Email Address
Date & Time of Incident
Time Reported to Work
Room # or Location
Incident Department (associated to the location of the Incident)
School / College
Incident / Accident? (injury, fire, damage)
Near Miss? (change in time or location would have been considerably worse)
Describe the incident, in detail, including the process, chemicals, equipment, and other personnel.
Location Type of the Incident
Was there a written SOP for the procedure that was performed?
Were there any injuries?
Did anyone seek medical treatment as a result of this incident?
Was there any building damage?
Was there any equipment damage?
Type of Incident
Source of Incident
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 been identified that still need to be implemented? Describe any obstacles preventing the implementation of identified corrective actions.
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