Location of incident:

*Building: Disque Hall Stratton Hall   *Room Number:

*Name of laboratory supervisor:

Date and time of incident:

*Date: *Time: (include am or pm)

*Name(s) of person(s) involved in the incident (include Drexel ID number if available):

Name(s) of  witness(es) to the incident (include Drexel ID number if available):

*Description of the experiment/work/operation being performed when the incident occurred:

*Explain the nature of the incident:

*Was medical attention required? yes no

If yes, explain the nature of the injuries requiring attention:

If yes, explain how the injuries were treated:

What preventive measures could be taken to prevent incidents such as this or reduce their severity:

If applicable, describe what preventative measures have been taken to avoid future incidents such as this:

*Was Drexel Security notified of the incident? yes no

If yes, name or ID number of the responding officer:

*Was the Drexel University Safety & Health Department notified of this incident? yes no

*Was the laboratory supervisor notified of the incident? yes no

*Name of person preparing this report:

*Phone number:

*E-mail address:

*Please type the characters above: