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Research AdministrationBiohazards and Lab Safety:
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Incident No. ___________________________
RHODE ISLAND HOSPITAL CHEMICAL SPILL INCIDENT REPORTSPILL LOCATION INFORMATION Date ______Day ______ Time _________ Building Floor ________________________ Room __________ Fire Dept. Response: ______________________ Method of Notification: _____________ Phone ______ Alarm ______ Other Person Initiating Notification ____________________
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 ______________________________________________________________ ______________________________________________________________ |
