SAN DIEGO STATE UNIVERSITY

ENVIRONMENTAL HEALTH & SAFETY

ACCIDENT/INCIDENT REPORT
Please complete a report for each incident or accident within 14 days of the date the incident or accident was
reported.
This form must be completed in the event of a potential exposure, chemical, biological, or radiological spill, fire, explosion,
impact, puncture, electrical shock, fall, entrapment etc. regardless of whether an injury or illness occurred. It may be
completed by the person affected by the incident, a witness, or the supervisor or manager.
In the event of an injury or illness, the Supervisor’s Report of Work Related Accident/Illness form must also be completed if
the affected individual is an employee of the University
Complete the form by typing or printing the response clearly. Check all applicable boxes.
Employee       Department:       Phone:      
Involved in the
Incident:

Date of Incident:(Month-Day-Year) Time of Incident Employee Email Employee Age

     /     /           :      am/pm            

Manager or Supervisor of Phone Number Was the manager or supervisor notified of the
Employee: accident/incident? Yes No
      (     )     -      Supervisor Email:      

Nature of the Incident/Injury: (Check All That Apply) Body Part Affected: (Check All That
Biological Exposure Chemical Exposure Radiation Exposure Apply)
Biological Spill Absorption Radiological Spill Finger Face/Head
Asbestos Exposure Ingestion Fire Hand Torso
Electrical Shock Inhalation Suffocation Arm Whole Body
Crush/Impact/Compression Injection Abrasion Toes Eye
Fall Chemical Spill Flying/Falling Debris Foot Skin
Explosion Bite Burn Leg Lungs
Laceration Heat Illness Puncture/Needlestick Throat
Entrapment Fainting/Loss of Consciousness Mucous Membrane
Other:      Other     

What happened? Describe how the incident/accident* occurred? Include what occurred prior to the accident/incident: (If more
space is needed, attach separate sheet of paper. Include materials, equipment and tools being used. If needed, attach photos or drawings and mark location.)
*If accident/incident involved sharps, the Sharps Injury Log must also be completed.
     

If applicable, what object or substance directly harmed the employee?

     

Location/Work Area Where Incident Occurred: (Check All That Procedure Being Performed at Time of Incident: (Check All
Apply) That Apply)
Medical Facility Laboratory/Classroom/Field Handling Haz. Materials Handling Hazardous Waste
Service/Utility Area Office Space Construction/Demolition Administering First-Aid
Athletic Field/Gym Recreation/Fit Center Animal Husbandry Office task
Construction Site Animal Facility Trenching Confined Space Entry
Workshop/Studio Performing research procedure, indicate procedure:      
Other:      Performing clinical procedure, indicate procedure:      
Bldg. or Grounds Maintenance/Service
Other:     
EHS,SDSU Rev 12/2015
PPE Worn by Employee at Time of Exposure: (Check All That What safety equipment was used to control hazard?: (Check All
Apply) That Apply)
Respirator-Half or Full Face: Cartridge:      Biological Safety Cabinet Containment/Isolation
Dust Mask (N95) Fume Hood Canopy duct
Hand Protection Hearing Protectors Elephant Trunk/Snorkel Machine Guard
Eye Protection Foot Protection Barrier None
Head Protection None Other:     
Other:     

What specific safety and hazard references (e.g., SDS, operator instruction manual, standard operating procedure) were
consulted and what safety/hazard training was completed prior to work with the substance or equipment that was involved in
the incident? (Please include dates of training)
     

What emergency safety Eyewash Fire Extinguisher

equipment or supplies where Safety Shower Spill Kit
used? First Aid Kit Other: _____________

Was an emergency call made to University Police (x41991 or Was emergency transport needed?
911)?
Yes No Yes No
Did affected If Yes, where? Did the employee refuse treatment?
employee seek
medical attention?
Yes No       Yes No

What was the response to the accident/incident?

     

Witness to Accident/Incident? Yes No

List name(s) of witness
      Phone (     )     -     
      Phone (     )     -     

Where other Employees Injured? Yes No

      Phone (     )     -     
      Phone (     )     -     

Person Completing Form:       Signature: Date      

Signed:
Title/Position:       Department:       Phone: (     )     -      Date      
Completed:

Accident/Incident Report must be submitted to:

Environmental Health & Safety, San Diego State University, 5500 Campanile Drive San Diego CA 92182-1243
Phone: (619) 594-6778 Fax: (619) 594-2854 EH&S Website: http://bfa.sdsu.edu/ehs/

EHS,SDSU Rev 12/2015