NIMBB Equipment, Resources, and Facilities Incident Report Form
Please use this form to report problems and issues related to equipment and facilities that need immediate attention, equipment to be condemned, and accidents in the laboratory.
Full Name
*
First Name
Last Name
Email
*
example@example.com
Designation
*
URA
Project-based RA
Graduate student
Undergraduate student
Lab Aide
Faculty
Other
Laboratory Affiliation
*
ABL
DMBEL
FGL
LMCB
MEL
MTRL
NBL
PSIL- DMB
PSIL-NADB
PIGGL
PMBPVL
DML
Other
Which of the following would you like to do?
Report an equipment for repair or preventive maintenance
Report an equipment for diposal
Report an issue with laboratory/ facility
Report a laboratory accident
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Equipment for repair or preventive maintenance
Name of equipment
*
Brand and Catalog Number
*
Location of equipment (floor, room)
(i.e 2nd flr, MDIC)
Upload an image of the property tag ID
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Report date and time:
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and time when incident occurred:
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Describe problems or issues with the equipment :
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Equipment to be condemned
Name of equipment
Brand and catalog number
Location of equipment (floor, room)
(2nd flr, MDIC)
Property tag ID/ number
Upload image of property tag ID/ number
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Lab that purchased the equipment
ABL
DMBEL
FGL
LMCB
MEL
MTRL
NBL
PSIL- DMB
PSIL- NADB
PIGGL
PMBPVL
SML
Other
Reason for disposal
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Facilities
Location (floor, room)
(3rd flr, male bathroom)
Date and time when incident occurred
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Describe incident, issues and concerns with this room/ facility.
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Laboratory Accident
Name of personnel involved
First Name
Last Name
Emergency contact person
First Name
Last Name
Mobile number of emergency contact
Location of incident
Date and time when incident occurred
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Describe the incident
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Next
Thank you for your submission.
The NIMBB Lab Manager or Deputy Director will get in touch with you as soon as possible.
Submit
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