Undergrad labs Incident report

Undergraduate Instructional Labs Incident Report

TA Name:	Course:
Student Name:	Incident location (Building, room):
Student ID:	Date and time:
Experiment being performed:
Details of incident Chemical Hazard If chemical hazard, describe the chemical involved, amounts and / or concentrations, type of exposure and where on the body it occured Physical Hazard If physical hazard, describe the injury (cut, burn, etc.), where on the body it occured and what caused it.
Was protective equipment properly worn at the time of the incident Yes No If Yes, What type? If No, Why?
Did you and the student discuss whether they should go to the Engemann Student Health Center? Yes No Explain: Did the student agree to go to the Engemann Student Health Center Yes No If the student agreed to go to the Health Center, The name of the person who escorted them was: If the student was advised to go to the Health Center and is declining, their electronic signature is required: Name: Date: