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.