Accident Report

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INCIDENT REPORT INSTRUCTIONS
Northwestern University  Vice President for Research  University Safety Committees  Office for Research Safety

***A sample completed form is appended to these instructions.*** When to Submit an Incident report An incident report must be delivered to the Office for Research Safety within five days of the incident. Reports are reviewed by the Chemical and Biological Safety Committee, or the Radiation Safety Committee.  An incident is defined as any unplanned and unwanted event that occurred during the performance of work activities and that resulted in or could have led to injury or material damage to property. Incident repercussions range from minor (e.g., a broken mercury thermometer) to significant (e.g., a 5-gallon bottle of sulfuric acid dropped in a heavy-traffic hallway).  An Incident Report is appropriate for “near misses,” incidents not resulting in personal harm or property damage, but which might have, under slightly different circumstances.  The Incident Report requires responses from (I) the person involved, (II) any witnesses to the incident, and (III) the Principal Investigator/Supervisor. Attach additional pages if necessary to complete the report. Reports that are not signed by the PI/supervisor will be returned for completion. The committees require input from the supervisor. See completed Example following the instructions.  Commonly, there are multiple causes in any given incident—all of which should be identified. Provide a complete and detailed response to each question, making a serious attempt to identify all “root cause(s).” The contributing factors were probably evident, but overlooked or unrecognized previously. These factors become more distinctly identifiable in light of the specifics of the incident A well-planned work process will include multiple layers of safeguards. Once causes are identified at all levels, consider safeguards and procedures that might be changed to prevent future incidents. .  This report is not intended to assign blame; it should be used as a tool to foster recommendations for procedural improvement. A well-prepared report will identify all work systems that need to be redesigned to compensate for foreseeable human errors. Information gleaned from these reports will also be used to improve safety policies.  The Incident Report is required for all incidents, and must be submitted to the Office for Research Safety within 5 business days of the incident. Delaying may result results in lost or forgotten details. Your department will be contacted by the Office for Research Safety if an incident report is not received promptly.

Incident Response
 Please refer to the Emergency Response Training Fact Sheet Section 6.3.4 of Chemical and Biological Safety in Laboratories for definitions of incidental spills you can clean up yourself versus major spills that require assistance, either by ORS or an outside agency. When in doubt, contact ORS for help. Both types of spill require an incident report.  Emergency Phone Numbers and procedures may be found in your department emergency evacuation plan, your Safety Desk Book, your Employee Safety Handbook, or the Office for Research Safety web page: http://www.research.northwestern.edu/research/ors/emerg/index.htm The Incident Report Form is located at http://www.research.northwestern.edu/research/ORS/online_forms.htm under Laboratory Safety Forms.

Incident Report Instructions and Sample Updated 4/18/2007

INCIDENT REPORT SAMPLE
Northwestern University  Vice President for Research  University Safety Committees  Office for Research Safety

***Instructions on when and how to complete this form may be found at http://www.research.northwestern.edu/research/ORS/online_forms.htm under Laboratory Safety Forms. ***

Hint: Save this file to your computer, complete your section, email a copy to the next person for their part, and when all information has been entered, printed, and signed by...
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