University of St. Francis - Chemical Hygiene Plan

SPILL / HAZARDOUS MATERIAL INCIDENT/ACCIDENT REPORT

Submit one report per individual involved in spill.

Spill / Accident Reported by:

Name____________________________ Title____________________________

Department: ____________________ Bldg ________ Room _____________

Phone ___________________

Spill / Accident Incident Information:

a. Spill / accident Occurred: Date: ______________ Time: __________

b. Spill / accident location (building, room, area and surface or space involved):

c. Hazardous Material Information:

1. Name of material(s) \ chemical(s) spilled:

2. Amount (of each agent) spilled:

3. Material Hazard Characteristic ( as appropriate): Toxic ( ) Flammable ( ) Corrosive ( ) Oxidizer ( ) Toxin ( ) Reactive ( ) Radioactive ( ) Biological ( ) Solid ( ) Liquid ( ) Gas ( )

4. Severity of spill (Check one): Minor__________ Major ___________

d. Description of Accident / Circumstances:

e. List person(s) Involved in spill:

f. Actions Taken (check and enter appropriate information):

1. Informed Supervisor\Safety Officer (Name): _______________ Time:________

2. Others informed:____________________________ Time:______________

3. Other Actions Taken (check and fill in information):

                                                                                                Time

a).____ Consulted MSDS                                           _________

b).____ Closed Laboratory\Wing Doors                   _________

c).____ Sounded Fire Alarm                                   _________

d).____ Called Ambulance                                           _________

e).____ Called Fire Department                           _________

f) ____ Consulted Chemical Data Base                   _________

3. Injuries (check yes or no): ____ yes _____ no __________

If yes, fill in information below:

        Name of person(s) injured Type of injury       USF Employee
                                                                          ( Yes or no)

a. ____________________ ________________           _____

b. ____________________ ________________           _____

c. ____________________ ________________           _____

6. Clean-up Procedures Performed:   

Signature and date or individual filing report:

_______________________________________________________________
                 (signature)                                                            (date)