Accident Report Form

<%@ LANGUAGE="VBSCRIPT" %> <% ' check the incoming user ThisSession = Request.ServerVariables("REQUEST_METHOD") If Not ThisSession = "POST" Then Response.Redirect("report_form.asp") End If For each x In Request.Form If Not IsEmpty(Request.Form(x)) Then Session(x) = Request.Form(x) End If Next session("txtReviewer") = session("FirstName") & " " & session("LastName") %> Accident Report Form

ACCIDENT REPORT FORM

Department of Chemistry
University of Wisconsin-Madison

(1) Date of accident: <%= session("acc_date")%> Time of accident: <%= session("acc_time")%> Room number: <%= session("room")%>

(2) Course number: <%= session("course")%> Section number: <%= session("sect")%>

(3) Person(s) injured: <%= session("injured")%>

(4) Witnesses: <%= session("witness")%>

(5) Circumstances that led up to the accident:

<%= session("preamble")%>

(6) The accident:

<%= session("accident")%>

(7) Type of injuries observed and the aftermath:

<%= session("after")%>

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

<%= session("recommend")%>

<%If Not session("role") = "NA" Then response.write("

" & "(9) Submitted by: " & session("submitter") & ", " & session("role") & "

") Else response.write("

" & "(9) Submitted by: " & session("submitter") & "

") End If%>

Signature: __________________________________________

Signature: __________________________________________ (date)________________
Chairman, Chemistry Department Safety Committee

Research Labs: submit completed report to Dr. Gordon Bain, room 1317 Chemistry
Instructional Labs: submit completed report to your Lab Director

<% response.write "Date and time this form was completed: "&date&" at "&time%>