The following information should be provided to the
examining physician.
Employee Name: |
Date of Incident: |
Department: |
Chair: |
Identity of the hazardous chemical(s) to which the employee may have been exposed:
Duration of exposure:
Amount of chemical(s) involved:
Description of the incident:
Control measures used at time of incident (fume hood, personal protective
equipment etc.)
Location of injuries or sites of contact, e.g. eyes, skin:
Signs and/or symptoms, if any:
Are signs and symptoms same as indicated on MSDS?
Witnesses (include telephone numbers):
____________________________ Signature |
________________ Date |