Appendix E. Non-Injury Incident Reporting Form

Campus: ______ Room: _______ Time/Date: __________

I. Type of problem (to be filled out by person reporting the problem)

_____ equipment failure _____ missing equipment/supplies

_____ lack of cleanliness _____ electrical hazard

_____ unknown/unlabeled chemicals _____ water leak/hazard

_____ spill _____ventilation hazard

_____ security problem _____ facilities failure

II. Nature of problem (to be filled out by person reporting the problem)

Please describe the problem and its location.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________

Name: ____________________________________ Date: _____________

Telephone: _________________ E-mail: ________________________

III. Problem Resolution (to be filled out by person(s) resolving the problem)

Please indicate who addressed the problem and how it was handled. Indicate what follow-up measures were taken, if applicable.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Name: _________________________________ Date: _________

fax to: Debbie Sackett (for Chemistry) at 223-2046 or Sarah Strong (for Biology) at 223-6769 or Bob Blodgett (for Physical Sciences) at 223-4641.