1. SCIENCE LABORATORY STUDENT ACCIDENT/INCIDENT REPORT FORM
      1. Faculty Member (Lab Instructor)’s Description of Accident/Incident:



SCIENCE LABORATORY
STUDENT ACCIDENT/INCIDENT REPORT FORM

Student Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
 
 

Name:                                                   
    Last          First        Middle
 
 
 
 
 
Student ID            Cell/Daytime Phone
 
 
 
Home Address:
(city/state/zip)
 
 
Faculty Member (Lab Instructor) Information - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
 
 
 
 
 
Name:                                                           Title  
 
 
 
 
 
Cell/Daytime Phone            Program
 
 
Description of Accident/Incident  - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
 
 
 
Date of Incident/Accident

Exact Location of Accident (Campus, Building, Room number)
 
 

 
 

 
 
Describe Equipment/
Materials/Chemicals Being Used
 

                          
First Aid Administered?
Yes No
Witnesses (include names, affiliation, and phone numbers if available):
Student’s Description of Accident/Incident:  
Initial here if I (student) declined first aid: ________________(initials)
_________________________________________
______________________
Student’s Signature Date



Faculty Member (Lab Instructor)’s Description of Accident/Incident:
 

 
 
 
 


_________________________________________    ____________________________
Faculty Member’s Signature          Date
_________________________________________    ____________________________
RECEIVED: Department Chair’s Signature      Date

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FORM AA-001/01 (11/18)

Copies to: Department Chair, Science & Math Division Dean; and Safety and Risk Manager