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James Madison University
Laboratory Incident Report
Date:
Time:
Location:
Date of report:
Incident Type – injury, fire, near miss, etc.
Name of person involved - print:
Address
room, apartment :
building, street
Telephone:
Cell:
Sign:
E-mail:
Name of person reporting - print:
Telephone:
Cell:
Sign:
E-mail:
Name of witnesses - print:
Telephone:
Cell:
Sign:
E-mail:
Name of witnesses - print:
Telephone:
Cell:
Sign:
E-mail:
Incident
Description of Incident:
Corrective Actions Taken:
Additional Corrective Actions Planned:
Forward
copy to:
Biology Safety Officer Robert Walters Bioscience 3028H email [email protected]
Revised March 2016
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