ACCIDENT REPORT FORM

Department of Chemistry
University of Wisconsin-Madison

INSTRUCTIONS: Please fill in all fields. Use "NA" if a field does not apply to your circumstances.

(1)  Date of accident (MM/DD/YYYY)       Time of accident       Room number

(2)  Course number (e.g., 103-1)       Section number

(3)  Name(s) of person(s) injured

(4)  Names of all witnesses (please use commas between names)
      

(5)  Circumstances that led up to the accident
      

(6)  The accident
      

(7)  Type of injuries observed and the aftermath
      

(8)  Recommendations that might help prevent a recurrence of the accident
      

(9)  Your name       Your title (e.g., TA)

***Double-check that you have filled in all fields.***

Click on the button below when you are finished typing your answers. A report form will be generated in a new window. Proofread the report, then print it. To make corrections, use the back button to return to this form. Make your corrections and re-process before printing.

This is not an electronic submission. You must print a paper copy of this report and file it with the Safety Committee chair or Lab Director.