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VTChem Safety Incident Report
Instructions: Complete all questions and click on the
Done
button at the bottom of the page. If you are unable to submit this online form, please email information to tissue@vt.edu.
Incident date:
Incident time:
Incident location:
Your name:
Your pid (email):
Your status:
Undergrad
Grad student
Faculty/staff
Visitor
Advisor, instructor, or course #:
List GTA, if applicable, and any other persons who were involved or witnessed the incident:
Check any and all that occurred:
injury or illness
fire
explosion or implosion
chemical exposure
flood
Other
If there was an injury or illness, check all that apply:
cut or puncture
fainting
nausea or dizziness
thermal burn
chemical burn
electric shock
Other
If there was a fire, check all that apply:
solvent
electrical
wood or paper
solid chemical or metal
Other
If there was a chemical exposure, check all that apply:
spill
leak
container break
skin contact
vapor inhalation
liquid or solid ingestion
Other
List chemicals in an exposure incident:
Check any safety equipment that was in use before the incident occurred:
SDS
gloves
eye protection
lab coat or apron
secondary container
fume hood
blast shield
glove box
Check any safety equipment that was used to remediate the incident:
SDS
gloves
eye protection
lab coat or apron
secondary container
fume hood
spill control kit
first aid kit
eye wash
emergency shower
fire extinguisher
soap and water
Other
Check any emergency services that were requested or received:
stockroom staff
police
rescue squad
fire department
Va Tech EHS
other medical services
poison control
Other
Do you feel you were adequately equipped, trained, and prepared for such an incident?
Yes
No
If no, please explain:
Please describe 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. You may email photos to tissue@vt.edu.
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