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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 copies
to: office of Risk
Management
131 West Grace Street, MSC 6703, Harrisonburg, Virginia, 22807
(540) 568-7812, FAX: (540) 568-2878, [email protected], http://www.jmu.edu/riskmtmt/
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