The purpose of this report is to describe the details of a laboratory accident that resulted in personal injury or exposure to infectious or radioactive materials. The information in this report will assist in evaluation measure to treat the injured or exposed person and to prevent similar incidents from occuring.
Name of injured or exposed person:
Date of accident:
Location:
Witnesses and/or other persons in the immediate vicinity:
Describe in detail the nature of the accident, including events leading to the accident:
Describe the method of first aid or other treatment that were undertaken immediately following the accident:
Was a physician consulted regarding injury/exposure?
Name of physician:
A. Potentially Infectious Material
1. What was the nature of the material known or presumed to be infectious (e.g. plasma, tissue culture
supernant)?
2. Is a sample of this material still available?
3. If known to be infectious, what pathogen was in the material and what was the concentration/titer?
B. Radioactive Material
1. What was the nature of the material (e.g. labeled cells, aqueous solution)?
2. What isotope and quantity was involved?
C. Protective Measures
1. What was the injured/exposed person wearing at the time of the accident?
2. What protective measures were employed at the time of the accident (e.g. biohazard hood, lead shielding)?
3. What additional measures could have been taken that may prevented or reduced the severity of the accident?
4. Should additional equipment that is not currently available be obtained to prevent this accident in the future?
Person completing form: Date:
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