Hazardous Contact Incident Report Form
Report details of hazardous contact incidents to ensure prompt response and safety compliance.
Incident Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Location (Building, Room, or Area)
*
Name of Person Reporting
*
First Name
Last Name
Name of Affected Person (if different from reporter)
First Name
Last Name
Hazard or Material Involved
*
Type of Exposure or Contact
*
Direct skin contact
Inhalation
Ingestion
Eye contact
Other
Describe the Incident
*
Immediate Actions Taken
*
Symptoms or Injuries Observed
*
Preferred Follow-up Method
*
Email
Phone
No follow-up needed
Submit Report
Should be Empty: