COSHH Incident Report Form
Report incidents involving hazardous substances to ensure safety and compliance.
Reporter Full Name
*
First Name
Last Name
Reporter Email Address
*
example@example.com
Reporter Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date and Time of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Describe the Incident
*
Hazardous Substance Involved
*
Type of Exposure
*
Inhalation
Skin Contact
Eye Contact
Ingestion
Injection
Other
Persons Affected (Names and Roles)
Immediate Actions Taken
*
Was Medical Attention Required?
*
Yes
No
Follow-up Actions or Recommendations
Has the Supervisor/Manager Been Notified?
*
Yes
No
Signature of Reporter (Confirming Accuracy of Report)
*
Submit Report
Submit Report
Should be Empty: