Hazardous Materials Exposure Report

Laboratory Incident Report Directions: All incidents must be documented and reviewed to determine what, if any, actions are required to minimize future occurrences. Using a pen, LEGIBLY write in the information below. Following immediate notification, the written report must be submitted within three calendar days. This information may be used in training and/or informational sessions with other lab personnel.

GENERAL INFORMATION Date Reported (mm/dd/yy): Time Reported:

 am

 pm Immediate Notification Provided to: Type of Immediate Notification:

 Lab Manager ______ E-mail

 Principal Investigator ______ Fax

 Animal Facility Supervisor  Telephone ______ In person  University Biosafety Officer  Other: ______ Other: ______

Type of Incident:

 Occupational exposure, known

 Occupational exposure, potential

 Release or spill outside of biosafety cabinet

 Theft (i.e., unauthorized removal of research materials)

 Loss (i.e., failure to account for research materials)

 Loss of directional air flow

 Security breach

 Severe weather/natural disaster

 Fire, gas leak, explosion

 Power outage

 Suspicious package

 Bomb or any other type of threat

 Workplace violence

 Facility issue

 Other: ______

Report Completed by: 1 Virginia Tech EHSS Form (06-2008) Laboratory Incident Report DESCRIPTION OF INCIDENT Date of Incident: Time of Incident:

 am

 pm Location of Incident (building, room #, where in the room):

Material(s)/Container(s)/Volume(s) Involved:

Equipment Involved:

 Centrifuge

 Incubator

 Water bath

 Biosafety cabinet

 Other: ______

Personal Protective Equipment in Use at the Time of Incident:

Detailed Summary of Events:

2 Virginia Tech EHSS Form (06-2008) Laboratory Incident Report POTENTIAL CAUSES OF INCIDENT What unsafe actions may have contributed to the incident?

What unsafe working conditions may have contributed to the incident?

IMPACT OF INCIDENT Hazards Posed by Incident:

Name(s) of Personnel Affected:

Body Areas Affected:

Medical Treatment Offered? Yes No

Medical Treatment Received? Yes No

If medical treatment was received , provide name of attending physician and summary of treatment prescribed:

Property Damage:

3 Virginia Tech EHSS Form (06-2008) Laboratory Incident Report Environmental Impact:

ACTIONS TAKEN Any local, state, and/or federal agency involvement? Yes No If yes, list the agency, contact, and phone number.

Area was Decontaminated? Yes No

 Lysol

 Bleach

 70% Ethanol

 Other: ______

Internal Review of Incident and Laboratory Procedures and Policies Conducted by:

 Lab Manager

 Principal Investigator

 Lab Personnel

 Animal Facility Supervisor

 University Biosafety Officer

 Other: ______

Date of Review (mm/dd/yy):

Changes to Procedures or Policies to Occur as a Result of Review:

4 Virginia Tech EHSS Form (06-2008) Laboratory Incident Report 5 Virginia Tech EHSS Form (06-2008) Laboratory Incident Report