Chemical Exposure Form

Name of exposed individual Name of exposed individual * First Last
Job Title / Position: *
Department: *
Date of exposure Date of exposure * / MM / DD YYYY
Time of exposure Time of exposure * : HH MM AM/PM
Location of incident (Bldg, Rm#): *
Type of exposure *

Type of exposure Dermal Inhalation injection Eyes
Location (i.e., left hand, index finger, right side of face). *
Chemical / substance involved: *
Solid or liquid: *
Estimated quantity involved: *
Was there a break in the skin or was substance injected into individual? *

Was there a break in the skin or was substance injected into individual? Yes No
Witness:
Explain in detail what occurred including procedure being performed at the time of the injury/incident: *
What Personal Protective Equipment (PPE) was being used? *

What Personal Protective Equipment (PPE) was being used? Gloves Safety Glass or Goggles Lab Coat FaceShield
What First Aid was perfomed/provided? *
Comments on the exposure incident (E.g. additional relevant factors involved): *
Date of report Date of report * / MM / DD YYYY
Report Prepared by: Report Prepared by: * First Last
Is Medical Care needed/required? *

Is Medical Care needed/required? Yes - Ensure the exposed indivdual has a copy of this form, and Safety Data Sheets attached so they can provide them to Healthcare specialist. No