Chemical Safety Incident Report Form

Use this form to report any chemical-related incidents (e.g. spills, exposures, fires, explosions, or near misses) on UW–Madison campus and laboratories. This submittal will allow us to follow up, identify potential causes, and develop preventative measures for all campus labs.

If you are reporting an emergency situation in which there is an immediate threat to health or life, please call 911.

Please note that this report does not replace injury reports for Workers’ Compensation claims. For information and instructions on Workers’ Compensation, please visit the Risk Management website.

INSTRUCTIONS:

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 Chemical Safety.
If you need assistance completing this form or reporting an incident, please call Chemical Safety at 608-265-5700.
After successful submission, a confirmation email will be sent to the Contact Email listed on the form. If this confirmation email is not received, an error has occurred. Please contact Chemical Safety at 265-5700 for assistance.

Chemical Safety Incident Report

Contact Name*
First Last
Contact Phone*
Contact Email*
PI Name
First Last
PI Email
Department
Campus Building / Location of Event
Date
MM slash DD slash YYYY
Names of Individuals Involved
Contact Email
Contact Phone
Brief Description of Event:
Brief Description of Response: