3101 Science Circle CPSB 102A
3101 Science Circle CPSB 102A
Anchorage, AK 99508
Laboratory Injury Report
Any accident that involves an injury requires at least two of these forms to be filled out, one by the party involved in theaccident and the other by the instructor and / or a witness. The forms must be completed immediately, unless prevented by the extent of the injuries. Completed forms should be turned in to Laboratory Support (CPSB 102A, Krystal Haase) within 24 hours of the accident / incident.Fill out all blocks “click here to enter text”.
General Information:
Name of Injured Person Click here to enter text.Name of Instructor Click here to enter text.
Name of Witness Click here to enter text. (If witness is listed here they must fill out a separate form.)
Report Filer Information:
Name (Last) Click here to enter text. / (First) Click here to enter text. / (MI) Click here to enter text.University ID # Click here to enter text. / E-mail Click here to enter text.
Home Address Click here to enter text.
Home Phone Click here to enter text. / Work Phone Click here to enter text. / Cell Phone Click here to enter text.
Date of Accident Click here to enter text. / Time of Accident Click here to enter text. / Location of Accident Click here to enter text.
Instructor Click here to enter text.
Description of the Accident (how or what occurred):
Click here to enter text.Description of the Injury (cut, burn, allergic reaction, falling injury from fainting etc.):
Click here to enter text.Description of your Involvement in the Accident:
Click here to enter text.List all responders that were called and / or responded to this accident (Lab Support (staff), University Police (UPD), Anchorage Fire Department (AFD), Paramedics):
Click here to enter text.If health care was needed or requested by the injured party, list where and how the injured party was taken to the healthcare provider:
Click here to enter text.Additional comments (if necessary):
Click here to enter text.I hereby certify that all information stated above is true and that this incident involved no injuries.
Report Filer Signature: Click here to enter text. Date: Click here to enter text.
Instructor Signature: Click here to enter text. Date: Click here to enter text.
Created by M RinerRevision 2.4Date of revision 9/19/2013