Fillable Non Submit Hazardous Chemical Exposure Incident Report Form (State University of New York at Farmingdale)

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Non Submit Hazardous Chemical Exposure Incident Report Form (State University of New York at Farmingdale)

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Hazardous Chemical Exposure Incident Report
INSTRUCTIONS: Use the forms in this package to document routes and circumstances of a
hazardous chemical exposure incident.
Hazardous Chemical Exposure Incident Report
NAME OF
FORM
PAGE
ACTION
Part
1
1 – 2
1. Completed by employee
2. Employee receives a copy
3. Human Resources receives a copy
Part
2
3
1. Completed by Environmental Health and Safety Officer
2. Employee receives a copy
3. Human Resources receives a copy
Part
3
4
1. Completed by Exposed Employee’s Medical Care Provider
2. Medical Care Provider mails direct to Human Resources
3. Medical Care Provider mails direct to Environmental Health and Safety Officer
Part 3A
6
1. Completed by the Exposed Employee to record Medical Evaluation follow up
2. Employee mails direct to Human Resources
3. Employee mails direct to Environmental Health and Safety Officer
Part 3B
7
1. Completed by the Exposed Employee’s Medical Care Provider to
record Medical
Evaluation Follow-up
2. Medical Care Provider mails direct to Human Resources
3. Medical Care Provider mails direct to Environmental Health
and
S
afety Officer
Page 1
Hazardous Chemical Exposure Incident Report
Part 1 (to be completed by Employee)
P
lease print or type all information
DEMOGRAPHICS
Date (of form completion):
Department:
Work Telephone:
Employee’s Last Name:
Employee’s First Name:
Date of Birth:
Social Security #:
Home Telephone #:
Other Contact # (i.e. mobile):
EXPOSURE INCIDENT
Date of Exposure:
Time of Exposure (be sure to note a.m. or p.m.):
if they varied from your regular work duties). If varied, please explain why you were engaging in said
activity(ies) [include additional page(s), as necessary]?
Chemical Name
Amt.
Conc.
Chemical Name
Amt.
Conc.
1.
2.
3.
4.
Office of Environmental Health and Safety Rev. 04/14
Page 2
PERSONAL PROTECTIVE EQUIPMENT - PPE
Were you wearing any Personal Protective Equipment
(PPE) [i.e. safety glasses, lab coat, ear muffs, nitrile
gloves, etc.)?:
YES
NO
If YES, Describe what type:
Did the PPE Fail?
YES
NO
If YES, Describe how (provide additional detail
below, as needed):
INCIDENT EXPOSURE
What Part(s) of your Body was Exposed?
Estimate the Size or Area of your Body that was
Exposed:
How Long Did The Exposure Last (# of seconds, min., hours, etc.)?
Is a Safety Data Sheet (SDS) attached to this Report? YES NO
SIGNS AND SYMPTOMS
Did you develop or experience any signs or symptoms as a result of the exposure?
Y
ES
NO
If yes, list them below (i.e. headache, nausea, rash, etc.):
1.
2.
3.
4.
5.
6.
Are signs and symptoms currently present (at time of form completion)?
Y
ES
NO
Are the signs and symptoms those documented on the SDS? YES
NO N/A
Is Exposure monitoring data available?
YES
NO N/A
Employee Signature Supervisor’s Signature
Date Date
As stipulated and in accordance with 29 CFR 1910.20, the Occupational Exposure to Hazardous Chemicals in Laboratories standard 29
CFR 1910.1450, form and related documentation will be kept on file by Farmingdale State College for the length of employment and 30 years
thereafter. This form and related documentation will remain confidential. Personal identifying information will be released with your consent only.
Office of Environmental Health and Safety Rev. 04/14
click to sign
signature
click to edit
click to sign
signature
click to edit
Page 3
Hazardous Chemical Exposure Incident Report
Part 2 (to be completed by Environmental Health and Safety Officer)
Please print or type all information
DEMOGRAPHICS
Date (of form completion):
Name of EH&S Officer Completing
Form:
EH&S Officer Work Telephone:
Employee’s Last Name:
Employee’s First Name:
Employee Date of Birth:
Employee Social Security #:
Employee Home Telephone #:
Employee Other Contact # (i.e. mobile):
REPORTING
Is a Comprehensive Accident Report Detailing This Incident On file?
YES
NO
Is a SH 900 and Related Documents Detailing this Incident On File?
Y
ES
NO N/A
EH&S Officer Comment:
EH&S OFFICER TO SUBMIT
COMPLETED COPIES OF FORMS
PART 1 AND 2 TO:
[enter exposed employee’s name and address]
Farmingdale State College
ATTN: Marybeth Incandela
Director of Human Resources
Whitman Hall
2350 Broadhollow Road
Farmingdale, NY 11735
ph. (631) 420-2107
fax (631) 420-2489
marybeth.incandela@farmingdale.edu
Environmental Health and Safety Officer’s Signature Supervisor’s Signature
Date Date
As stipulated and in accordance with 29 CFR 1910.20, the Occupational Exposure to Hazardous Chemicals in Laboratories standard 29
CFR 1910.1450, form and related documentation will be kept on file by Farmingdale State College for the length of employment and 30 years
thereafter. This form and related documentation will remain confidential. Personal identifying information will be released with your consent only.
Office of Environmental Health and Safety Rev. 04/14
click to sign
signature
click to edit
click to sign
signature
click to edit
Page 4
Hazardous Chemical Exposure Incident Report
Part 3 (to be completed by Exposed Employee’s Medical Care Provider)
Please print or type all information
EXPOSED EMPLOYEE
Employee’s Last Name: Employee’s First Name:
Date of Birth:
Social Security #:
Work Site Name:
Work Telephone:
MEDICAL CARE PROVIDER
Health Care Professional Name: Title:
Office Telephone:
Office Fax Number:
MEDICAL CARE PROVIDER’S REPORT
Did You Treat The Patient/Employee Directly?
YES
NO
Medical Care Provider’s Signature Date
As stipulated and in accordance with 29 CFR 1910.20, the Occupational Exposure to Hazardous Chemicals in Laboratories standard 29
CFR 1910.1450, form and related documentation will be kept on file by Farmingdale State College for the length of employment and 30 years
thereafter. This form and related documentation will remain confidential. Personal identifying information will be released with your consent only.
Office of Environmental Health and Safety Rev. 04/14
click to sign
signature
click to edit
Page 5
MEDICAL CARE PROVIDER
TO SUBMIT COMPLETED
COPY OF FORM PART 3 TO:
Farmingdale State College
ATTN: Marybeth Incandela
Director of Human Resources
Whitman Hall
2350 Broadhollow Road
Farmingdale, NY 11735
ph. (631) 420-2107
fax (631) 420-2489
marybeth.incandela@farmingdale.edu
Farmingdale State College
ATTN: Jeff Carter, CHMM, MPS
Environmental Health and Safety Officer
Horton Hall
2350 Broadhollow Road
Farmingdale, NY 11735
ph. (631) 420-2105
fax (631) 420-9173
jeff.carter@farmingdale.edu
Office of Environmental Health and Safety Rev. 04/14
Page 6
Hazardous Chemical Exposure Incident Report
Part 3A (to be completed by Exposed Employee to record Medical Evaluation follow up)
Please pr
int or type all information
EXPOSED EMPLOYEE
Date (of form completion):
Department:
Work Telephone:
Employee’s Last Name:
Employee’s First Name:
Social Security #:
Job Title at Time of Exposure:
Date and Time of Exposure:
Date of Follow Up:
Name and Location of Medical Treatment Facility:
Reason for Follow Up:
EMPLOYEE TO SUBMIT
COMPLETED COPY OF
FORM PART 3A TO:
Farmingdale State College
ATTN: Marybeth Incandela
Director of Human Resources
Whitman Hall
2350 Broadhollow Road
Farmingdale, NY 11735
ph. (631) 420-2107
fax (631) 420-2489
marybeth.incandela@farmingdale.edu
Farmingdale State College
ATTN: Jeff Carter, CHMM, MPS
Environmental Health and Safety Officer
Horton Hall
2350 Broadhollow Road
Farmingdale, NY 11735
ph. (631) 420-2105
fax (631) 420-9173
jeff.carter@farmingdale.edu
Supervisor’s Statement/Comments (enter “N/A” if no additional information/detail warranted):
Employee Signature Supervisor’s Signature
Date Date
As stipulated and in accordance with 29 CFR 1910.20, the Occupational Exposure to Hazardous Chemicals in Laboratories standard 29
CFR 1910.1450, form and related documentation will be kept on file by Farmingdale State College for the length of employment and 30 years
thereafter. This form and related documentation will remain confidential. Personal identifying information will be released with your consent only.
Office of Environmental Health and Safety Rev. 04/14
click to sign
signature
click to edit
click to sign
signature
click to edit
Page 7
Hazardous Chemical Exposure Incident Report
Part 3B (to be completed by the Exposed Employee’s Medical Care Provider to record Medical
Evaluation
follow up)
Please print or type all information
MEDICAL CARE PROVIDER
Health Care Professional Name: Title:
Office Location (Street and Number, City, State, Zip):
Office Telephone:
Office Fax Number:
MEDICAL CARE PROVIDER’S REPORT
Employee Health File Reviewed?
YES
NO
Date of Review:
Medical Care Provider’s Findings & Observations:
Is Additional Follow Up Needed (if so, explain why):
Other Pertinent Information:
MEDICAL CARE PROVIDER
TO SUBMIT COMPLETED
COPY OF FORM PART 3B TO:
Farmingdale State College
ATTN: Marybeth Incandela
Director of Human Resources
Whitman Hall
2350 Broadhollow Road
Farmingdale, NY 11735
ph. (631) 420-2107
fax (631) 420-2489
marybeth.incandela@farmingdale.edu
Farmingdale State College
ATTN: Jeff Carter, CHMM, MPS
Environmental Health and Safety Officer
Horton Hall/Administration and Finance
2350 Broadhollow Road
Farmingdale, NY 11735
ph. (631) 420-2105
fax (631) 420-9173
jeff.carter@farmingdale.edu
Medical Care Provider’s Signature Date
As s
tipulated and in accordance with 29 CFR 1910.20, the Occupational Exposure to Hazardous Chemicals in Laboratories standard 29
CFR 1910.1450, form and related documentation will be kept on file by Farmingdale State College for the length of employment and 30 years
thereafter. This form and related documentation will remain confidential. Personal identifying information will be released with your consent only.
Office of Environmental Health and Safety Rev. 04/14
click to sign
signature
click to edit
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Non Submit Hazardous Chemical Exposure Incident Report Form (State University of New York at Farmingdale)

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Completed 23 July 2020

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