Toxic Plant Skin Exposure Incident Report Form
Report and document incidents involving skin exposure to toxic plants for proper follow-up and care.
Full Name of Exposed Individual
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (if available)
example@example.com
Date and Time of Exposure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (Where did the exposure occur?)
*
Relationship to Organization
*
Please Select
Employee
Visitor
Student
Contractor
Other
Plant Involved (if known)
Describe How the Exposure Happened
*
Symptoms Observed After Exposure
*
Redness
Blisters
Rash
Itching
Swelling
Pain
Other
First Aid or Actions Taken Immediately After Exposure
*
Was Medical Attention Sought?
*
Yes
No
Please provide any additional details or comments about the incident.
Submit Report
Should be Empty: