Incident Report

Report of an Incident in the Department of Chemistry (do not use this form if you are from another department)
For ANY INJURY, complete the PURDUE UNIVERSITY FIRST REPORT OF INJURY FORM.

Reporter
Maximum of 50 characters allowed. Currently Entered: 0 characters.
Who is reporting this incident?
Email
Phone (Optional) Phone (Optional) - ### - ### ####
Date Date / MM / DD YYYY
Time Time : HH MM AM/PM
Was there an injury

Was there an injury Yes No
Describe the Injury

Describe the Injury Cut (with bleeding) Cut (no bleeding) Burn (extreme heat) Burn (extreme cold) Strong acid exposure (skin, eye and/or mucus membrane) Strong base exposure (skin, eye and/or mucus membrane) Ingestion of chemical Malaise (dizziness, nausea, cramping...) Other (Specify in the “What Happened” section below)
Name of injured Name of injured First Last
Name of person who was injured
Was first aid administered?

Was first aid administered? Yes No
Who administered first aid?

Name of first responder
Was anyone exposed to blood?

Was anyone exposed to blood? Yes No
Who was exposed to blood?
Maximum of 300 characters allowed. Currently Entered: 0 characters.
List names of all exposed to blood
Transport to Medical Center?

Choose from list
Where did this happen?

Location of incident
What is the room number?
Was this in a course?

Was this in a course? Yes No
Course number
What experiment was being done?
Maximum of 150 characters allowed. Currently Entered: 0 characters.
Name the lab exercise
Who was supervising the lab?
Maximum of 150 characters allowed. Currently Entered: 0 characters.
Names of Teaching Assistant(s) and TA supervisor
Was this in a research lab?

Was this in a research lab? Yes No
Research Lab Advisor

Name of the professor in charge of the program
What happened?
Maximum of 500 characters allowed. Currently Entered: 0 characters.
Was this preventable?

Select from pulldown
Corrective and Preventative Action (CAPA)
Maximum of 500 characters allowed. Currently Entered: 0 characters.
Suggest a way to correct a problem or prevent it from happening again.
You should receive a confirmation email as soon as your report is successfully submitted. If not, please visit the Online Reporting system and try again.

Suggest a way to correct a problem or prevent it from happening again.