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Chemical Spill Report Form

(For reporting to the University Safety Office Only)

Spill Report

Department Name:   

Reporting Person:    Telephone: 

Reporting Person's Campus Address:

Date of Incident:

Time of Incident:  

Location: Room Number:  Building Name: 
Location/area outside of a building:

List all hazardous materials involved in the incident:

Describe how the spill occurred to your best knowledge. Include any relevant circumstances in as much detail as possible:

What containment measures were taken to control the spill:

What corrective actions were taken to control and clean up the spill:

List any existing or potential hazards that either caused or resulted from the incident:

Describe any first aid treatment provided, in detail:

List Full names and phone numbers of individuals who witnessed the incident:

Any additional information relating to the incident:

                                    (Print a copy for your records)