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 email@example.com.
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:
If there was an injury or illness, check all that apply:
If there was a fire, check all that apply:
If there was a chemical exposure, check all that apply:
List chemicals in an exposure incident:
Check any safety equipment that was in use before the incident occurred:
Check any safety equipment that was used to remediate the incident:
Check any emergency services that were requested or received:
Do you feel you were adequately equipped, trained, and prepared for such an incident?
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 firstname.lastname@example.org.