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NOTE:
This general template can be used for lab incidents. You can modify this template to suit your lab and internal OHS reporting requirements.

Incident Details

Building name

Room #

Date and time of incident

What was the Incident/ Near Miss?

Were there any injuries?

Description of injury

Take photo of injury

Was there any damage to equipment or the building?

Description of damage

Take photo of damage

What caused the incident?

Take photo of surrounding environment including any annotations

What actions will be taken to eliminate future repeats of the incident?

Supervisor comments

Sign Off

Signed off by supervisor when corrective actions have been adopted and monitored

Supervisor sign off

Lab Incident Report Template Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 50

Use this template to report any incidents in the lab including spills, leaks, cuts and any other injuries or property damage

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

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Audit

NOTE:
This general template can be used for lab incidents. You can modify this template to suit your lab and internal OHS reporting requirements.

Incident Details

Building name

Room #

Date and time of incident

What was the Incident/ Near Miss?

Were there any injuries?

Description of injury

Take photo of injury

Was there any damage to equipment or the building?

Description of damage

Take photo of damage

What caused the incident?

Take photo of surrounding environment including any annotations

What actions will be taken to eliminate future repeats of the incident?

Supervisor comments

Sign Off

Signed off by supervisor when corrective actions have been adopted and monitored

Supervisor sign off