Construction Site Incident Report - EHS

ENVIRONMENTAL HEALTH & SAFETY W: www.usf.edu/ehsM-F, 8-5: 813-974-4036 EHS RISK MANAGEMENT E: [email protected] P: 813-974-0869 CONSTRUCTION SITE INCIDENT REPORT - EHS

TO: EHS RM (RISK MANAGEMENT) INSTRUCTIONS TO CALLER: FOR NON-EMERGENCY (BUSINESS HOURS): COMPLETE THIS INCIDENT WILSON BULL REPORT FORM AND EMAIL TO EHS RM; FOLLOW UP WITH PHONE [email protected] 813-974-0869 CALL TO CONFIRM RECEIPT. AFTER HOURS AND ON WEEKENDS, CALL USF POLICE 911.

A. CALLER INFORMATION: (IF THIS IS AN EMERGENCY, PLEASE CALL 911) DATE: 1/1/2014 FIRM/DEPT.: PHONE: EHS Incident EHS ID: NAME: EMAIL: Report No

CAMPUS:  TAMPA  ST PETE  ST PETE  OTHER: Blue Text/Cell: EHS RM Use only

B. DESCRIPTION OF SERVICE REQUESTED: DESCRIPTION:USF Project Number, Name, Description BUILDING: Building No/Name EHS/RM REP TAKING CALL: EHS/RM REP ASSIGNED THE ROOM (S): List Room Numbers CALL

C. ASSIGNED AREA OF CONCERN: SAFETY & RISK FIRE PREVENTION BIOLOGICAL SAFETY LAB SAFETY TRAINING MANAGEMENT  ELECTRICAL  SEWER LINE BREAK  ASBESTOS  LAB TRAINING CHARGE  HURRICANE  FIRE & RESPONSE  FOOD HYGIENE  FUME HOODS EXPLOSION  THREAT TO WATER SYSTEM  CHEMICAL  GAS LINE LEAK  SANITATION SAFETY  WORKER’S  HEAT/ COLD  SAFETY COMPENSATION  BUILDING SAFETY  BIOLOGICAL WASTE STRESS SHOWERS/  FIRE ALARM  SHARPS  RPP EYEWASH UNITS  FLOODING HAZARDOUS  INSURANCE  IRRITANT SMELLS  LOCKOUT/ TAGOUT WASTE  WATER DAMAGE CLAIM  CHEMICAL FLOODING LABS  INDOOR AIR QUALITY  PPE RELEASE  ACCIDENT  SUSPICIOUS INVESTIGATION  VEHICLE RELEASE  HAZCOM SUBSTANCE

 MERCURY SPILL  BLOOD BORNE OTHER  MISCELLANEOUS PATHOGENS  Abbreviations: SHARPS (SHARP OBJECTS) RPP (RESPIRATORY PROTECTION PROGRAM) PPE (PERSONAL PROTECTIVE EQUIPMENT) HAZCOM (HAZARD COMMUNIUCAITONS)

D. EHS/RM RESPONSE ACTION: (EHS RM USE ONLY)

TYPE OF ACTUAL  EMERGENCY  IMMEDIATE  URGENT  ROUTINE REPONSES:  TO BE SCHEDULED ASAP  OTHER: ACTIONS TAKEN:

E. EHS/RM FOLLOW-UP MEASURES: (EHS RM USE ONLY) ARE FOLLOWING  NO  YES, EXPLAIN: MEASURES REQUIRED: EHS CLOSING TASK DATE: 1/1/2014 OUT:

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FPC REVISED: JULY 21, 2015 PAGE 1 OF 1