Middlebury Sciences Incident Reporting Form

Safety Incident: an event (accident, fire, spill, animal bite, etc.) that results in an injury or illness to an individual, damage to equipment/building, or a "near miss".

Near Miss: a potential hazard or an unplanned event that did not result in an injury, illness, exposure or damage - but had the potential to do so.  Incidents range from minor (e.g. a broken mercury thermometer) to significant (e.g. chemical fire).

See http://www.middlebury.edu/academics/resources/stss/sciences-ehs/incident-reporting for instructions to report an actual injury, illness, exposure or damage.

Please provide a complete and detailed response to each question, making a serious attempt to identify all "root cause(s)".

This report is not intended to assign blame; it will be used as a tool to foster recommendations for procedural improvement and to help prevent future incidences and injuries.

Please submit this form as soon as possible after the incident.

Approximate time is fine