PMG-57ENVIRONMENTAL HEALTH & SAFETY W: www.usf.edu/ehs M-F, 8-5: 813-974-4036EHS RISK MANAGEMENT E: wbull@usf.edu P: 813-974-0869

CONSTRUCTION SITE INCIDENT REPORT - EHSTO: EHS RM (RISK MANAGEMENT) INSTRUCTIONS TO CALLER:

FOR NON-EMERGENCY (BUSINESS HOURS): COMPLETE THIS INCIDENT REPORT FORM AND EMAIL TO EHS RM; FOLLOW UP WITH PHONE CALL TO CONFIRM RECEIPT. AFTER HOURS AND ON WEEKENDS, CALL USF POLICE 911.

WILSON BULLwbull@usf.edu 813-974-0869

A. CALLER INFORMATION: (IF THIS IS AN EMERGENCY, PLEASE CALL 911)DATE: 1/1/2014 FIRM/DEPT.: PHONE:

EHS ID: EHS Incident Report No NAME: EMAIL: CAMPUS: TAMPA ST PETE ST PETE OTHER: Blue Text/Cell: EHS RM Use only

B. DESCRIPTION OF SERVICE REQUESTED:DESCRIPTION: USF Project Number, Name, DescriptionBUILDING: Building No/Name EHS/RM REP TAKING CALL: ROOM (S): List Room Numbers EHS/RM REP ASSIGNED THE CALL

C. ASSIGNED AREA OF CONCERN:FIRE PREVENTION BIOLOGICAL SAFETY SAFETY & TRAINING LAB SAFETY RISK MANAGEMENT ELECTRICAL CHARGE SEWER LINE BREAK ASBESTOS LAB TRAINING HURRICANE

RESPONSE FIRE & EXPLOSION THREAT TO WATER SYSTEM

FOOD HYGIENE FUME HOODS GAS LINE LEAK SANITATION CHEMICAL SAFETY WORKER’S

COMPENSATION BUILDING SAFETY BIOLOGICAL WASTE HEAT/ COLD STRESS SAFETY SHOWERS/ EYEWASH UNITS FIRE ALARM SHARPS RPP FLOODING

HAZARDOUS WASTE IRRITANT SMELLS LOCKOUT/ TAGOUT WATER DAMAGE FLOODING LABS

INSURANCE CLAIM CHEMICAL RELEASE INDOOR AIR QUALITY PPE ACCIDENT

INVESTIGATION VEHICLE RELEASE SUSPICIOUS SUBSTANCE HAZCOM MERCURY SPILL BLOOD BORNE

PATHOGENSOTHER

MISCELLANEOUS Abbreviations: SHARPS (SHARP OBJECTS) RPP (RESPIRATORY PROTECTION PROGRAM)

PPE (PERSONAL PROTECTIVE EQUIPMENT) HAZCOM (HAZARD COMMUNIUCAITONS)

D. EHS/RM RESPONSE ACTION: (EHS RM USE ONLY)TYPE OF ACTUAL REPONSES:

EMERGENCY IMMEDIATE URGENT ROUTINE TO BE SCHEDULED ASAP OTHER:

ACTIONS TAKEN:

E. EHS/RM FOLLOW-UP MEASURES: (EHS RM USE ONLY)ARE FOLLOWING MEASURES REQUIRED:

NO YES, EXPLAIN:

EHS CLOSING TASK OUT: DATE: 1/1/2014

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