<p> 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.</p><p>GENERAL INFORMATION Date Reported (mm/dd/yy): Time Reported:</p><p> am</p><p> pm Immediate Notification Provided to: Type of Immediate Notification:</p><p> Lab Manager ______ E-mail</p><p> Principal Investigator ______ Fax</p><p> Animal Facility Supervisor  Telephone ______ In person  University Biosafety Officer  Other: ______ Other: ______</p><p>Type of Incident:</p><p> Occupational exposure, known</p><p> Occupational exposure, potential</p><p> Release or spill outside of biosafety cabinet </p><p> Theft (i.e., unauthorized removal of research materials)</p><p> Loss (i.e., failure to account for research materials)</p><p> Loss of directional air flow</p><p> Security breach</p><p> Severe weather/natural disaster</p><p> Fire, gas leak, explosion</p><p> Power outage</p><p> Suspicious package</p><p> Bomb or any other type of threat</p><p> Workplace violence</p><p> Facility issue</p><p> Other: ______</p><p>Report Completed by: 1 Virginia Tech EHSS Form (06-2008) Laboratory Incident Report DESCRIPTION OF INCIDENT Date of Incident: Time of Incident:</p><p> am </p><p> pm Location of Incident (building, room #, where in the room):</p><p>Material(s)/Container(s)/Volume(s) Involved:</p><p>Equipment Involved:</p><p> Centrifuge</p><p> Incubator</p><p> Water bath</p><p> Biosafety cabinet</p><p> Other: ______</p><p>Personal Protective Equipment in Use at the Time of Incident:</p><p>Detailed Summary of Events:</p><p>2 Virginia Tech EHSS Form (06-2008) Laboratory Incident Report POTENTIAL CAUSES OF INCIDENT What unsafe actions may have contributed to the incident? </p><p>What unsafe working conditions may have contributed to the incident?</p><p>IMPACT OF INCIDENT Hazards Posed by Incident:</p><p>Name(s) of Personnel Affected:</p><p>Body Areas Affected:</p><p>Medical Treatment Offered? Yes No</p><p>Medical Treatment Received? Yes No </p><p>If medical treatment was received , provide name of attending physician and summary of treatment prescribed:</p><p>Property Damage:</p><p>3 Virginia Tech EHSS Form (06-2008) Laboratory Incident Report Environmental Impact:</p><p>ACTIONS TAKEN Any local, state, and/or federal agency involvement? Yes No If yes, list the agency, contact, and phone number.</p><p>Area was Decontaminated? Yes No</p><p> Lysol</p><p> Bleach</p><p> 70% Ethanol</p><p> Other: ______</p><p>Internal Review of Incident and Laboratory Procedures and Policies Conducted by:</p><p> Lab Manager</p><p> Principal Investigator</p><p> Lab Personnel</p><p> Animal Facility Supervisor</p><p> University Biosafety Officer</p><p> Other: ______</p><p>Date of Review (mm/dd/yy): </p><p>Changes to Procedures or Policies to Occur as a Result of Review:</p><p>4 Virginia Tech EHSS Form (06-2008) Laboratory Incident Report 5 Virginia Tech EHSS Form (06-2008) Laboratory Incident Report</p>