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INCIDENT REPORT

Northwestern University v Vice President for Research v Chemical and Biological Safety Committee v Office for Research Safety

The Incident Report consists of three sections with required responses from the (I) person involved, (II) other individuals involved/witnesses, and the (III) principal investigator/supervisor. Use additional pages for responses as necessary. You are not limited to the given space. Return the completed report to the Office for Research Safety for review by the Chemical and Biological Safety Committee.

Respond to all questions thoroughly. Use this report as a tool to improve current practice. The report is not intended to assign blame; only to foster beneficial change.

____________________________________________

I. Report by Person Involved

Name

Date prepared

Position/Title (e.g., graduate student, technician)

Department

Principal Investigator/Supervisor

Location of incident

Date and time of incident

  1. Describe fully the operation prior to the incident, the event itself and the sequence of events that followed; list any equipment, machinery, and instruments in use at the time of the incident.
    2.

             

  2. Describe any injuries occurring from the incident and the treatment of the injuries.
    3.

             

  3. Describe any damage or property loss.
    4.

 

  1. Contributing/Mitigating Factors
    2.
  1. What do you perceive to be the causal factors behind this incident? This could include inadequate management oversight; lack of appropriate safety policy; proper equipment not used, required, or supplied; etc.
    2.

             

  2. What are your recommendations to prevent recurrence?
    3.

         

____________________________________________

II. Other Individuals Involved/Witnesses

Name

Position

  1. Description of Incident – Where were you and what were you doing when the incident occurred? What did you see?
    2.

             

  2. Additional comments or observations.
    3.

 

III. Report by Principal Investigator/Supervisor

  1. Contributing/Mitigating Factors – What do you perceive to be the causal factors behind this incident? This could include inadequate management oversight; lack of appropriate safety policy; proper equipment not used, required, or supplied; etc.
    2.

               

  2. Immediate corrective action taken.
    3.

               

  3. Additional remediation efforts to prevent future recurrence (and expected date of implementation).
    4.

               

  4. Comments
    5.

           

  1. Principal Investigator/Supervisor Signature
 

Please return completed report to ORS - Tech NG71, Evanston Campus or Ward B-106, Chicago Campus.
Date rec'd. ____________
WIDTH="58%" VALIGN="TOP"> 
Please return completed report to ORS - Tech NG71, Evanston Campus or Ward B-106, Chicago Campus.
Date rec'd. ____________
WIDTH="58%" VALIGN="TOP"> 
Please return completed report to ORS - Tech NG71, Evanston Campus or Ward B-106, Chicago Campus.
Date rec'd. ____________