Incident Reporting

Incident Reporting
Please complete this form to the best of your knowledge. It is required by HR of the EPL and is for the purpose of improving the Safety environment.
Incident Date

MonthDayYear
Incident Time

AM/PM Option
Report Date

MonthDayYear
Report Time

AM/PM Option
Error: Invalid date/time

Reporting cannot precede the incident. Enter a valid Date/Time
Incident Location
Incident Description
Reporter's Name
Reporter Job Title
Involved Person's Name
Anyone injured or became sick?
If the injured / sick person needed medical evaluation or treatment beyond the First-Aid, you are obliged to contact the HR representative (Lauren Gilmer / Isabelle Logossou : gilmer@carnegiescience.edu / ilogossou@carnegiescience.edu or call 202-478-8915) to complete an additional form. Nevertheless, describe the initial treatment and aids used, if any.

If the injury/sickness was treatable only with the First-Aid, describe the treatment and aids used.
Treatment of injury/sickness
Action taken by Safety Committee
Should be Empty: