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Transcript of · Web viewBuilding No/Name EHS/RM Rep Taking Call: Room (s): List Room Numbers EHS/RM Rep...
PMG-57ENVIRONMENTAL HEALTH & SAFETY W: www.usf.edu/ehs M-F, 8-5: 813-974-4036EHS RISK MANAGEMENT E: [email protected] 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 [email protected] 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
document.docx
FPC REVISED: JULY 21, 2015 PAGE 1 OF 1