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  • Biohazards and Lab Safety: Emergency Response to Spills

  • Incident No. _______

    THE MIRIAM HOSPITAL CHEMICAL SPILL INCIDENT REPORT

    SPILL LOCATION INformATION

    Date: _____ Day ____ Time _____ Bldg/Area _________________________

    Building Floor _______________________ Room _____ Dept: ________________

    Principal Investigator: ___________________________________________________

    Person Initiating Notification: ___________________ Dept: _________________

    Extension: _____________________________

    CATEGORY SPILL INCIDENT

    ___ Minor Spill (Handled in-house by laboratory personnel or Safety personnel using spill kit) - Type of Chem/Material __________________________________

    ____ Moderate Spill (requiring outside contractor-Clean Harbors) Type of Chem/Material ___________________________________________________________

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

    Type of Chem/Material _________________________________________________

    Responding Agencies or Departments ______________________(use back of form for details if more space needed)

    Cause of Spill (explanation of incident): _______________________________________________________________

    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 ___________________________________

    Methods and Materials Utilized for Clean Up: ________________________________

    Amount of Clean-UpWaste Generated ______________________________________

    A copy of this report must be sent to TMH Safety Office. Please call X 3-5060 for pick-up of chemical spill material or ESD X32448 for CHEMO spill material removal.