First Report of Biological Exposure or Release Event

This report, when submitted, provides the Office of Biological Safety (OBS), University Health Services (UHS) and the Institutional Biosafety Committee (IBC) with information to ensure that proper actions have been taken, including appropriate medical care, and helps the University meet NIH reporting requirements.

Instructions:

  • Use this form to report any and all potential exposures or releases of organisms or biological toxins on UW-Madison campus and laboratories.
  • Reporting must be completed within 24 hours of the event, and is the responsibility of the Principal Investigator (as stated in UW-Madison Institutional Biosafety Committee Policy IBC-POL-012).
  • Potential exposures include needle sticks, animal bites, aerosol exposures, and other incidents potentially resulting in disease.
  • Potential releases include spills outside of primary containment as well as potential releases to the environment.
  • Unauthorized releases of transgenic animals or plants should also be reported on this form.
  • After completing this form, select "Submit" at the bottom of this form. The information on this form will be sent to designated individuals at the Office of Biological Safety and the University Health Services.
  • Information on this form is used to determine how our offices may help you and your laboratory and for mandatory federal reporting purposes.
  • The submitter will be contacted for incident follow-up.
  • If you need assistance completing this form or reporting an incident, please call the OBS at 263-2037.

Form:

Please fill in ALL *Required fields before submitting the form.

PI Name:*
PI Phone:*
Contact Name:*
Contact Phone:*
Contact Email:*
Department:
Does this lab have a VA affiliation?**
      
Location of Event:
Nature of Event:
Date of Event (MM/DD/YYYY):
Time of Event (HH:MM AM or PM):
Names of Individuals Involved:
Organism/Toxin Involved:
Biosafety Level:
Does Your Exposure or Release Involve Recombinant Materials?:
      
If recombinant, what genes were introduced into the organism? (include toxins, antibiotic-resistant genes, or changes that may affect risks and treatment):
Brief Description of Event:
Brief Description of Response:
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