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  • Biohazards and Lab Safety: Emergency Response to Spills

  • Incident No. ___________________________

     

    RHODE ISLAND HOSPITAL CHEMICAL SPILL INCIDENT REPORT

    SPILL LOCATION INformATION

    Date ______Day ______ Time _________
    Bldg/Area _________________________________________

    Building Floor ________________________ Room __________
    Dept.: ________

    Fire Dept. Response: ______________________
    If yes, Time of Arrival __________

    Method of Notification: _____________ Phone ______ Alarm ______ Other

    Person Initiating Notification ____________________
    Dept. ________________

     

    CATEGORY OF SPILL INCIDENT

    ______ Minor Spill (Handled In-house) - Type of Chem/Material

    ______ Moderate Spill (requiring outside contractor) - Type of Chem/Material

    ______ Uncontrolled Spill (requiring Fire Department, RIDEM, or other agency notification) -

    Type of Chem/Material ______________________________

     

    Responding Agencies or Departments _______________________

     

    Cause of Spill __________________________________________________

     

    Hospital Employee(s) Responding to Spill;

     

    Name _____________________ Dept. __________ Phone No. ___________

     

    Name _____________________ Dept. __________ Phone No. ___________

    Name _____________________ Dept. __________ Phone No. ___________

     

    SPILL CLEAN UP INformATION

    Person Conducting Cleanup Activities ________________________________________________________

    Duration of Cleanup: From________________ To ___________________

    Methods and Materials Utilized for Cleanup _________________________________________________

    _____________________________________________________________

     

    Amount of Waste Generated _____________ Dept. Manager _____________

    Dept. Manager's Phone No. ________________

    Comments ______________________________________________________________

    ______________________________________________________________