Chemical Exposure Report

Emergency first

For a fire, a large release or anyone seriously hurt, call 911 now. Give first aid from SDS Section 4 (for eyes or skin, flush with water for at least 15 minutes). File this report once everyone is safe.

Use this form for any exposure to, or incident with, a hazardous chemical, however small. The report goes to the Director of Safety so the event is recorded and corrective action is taken. No login needed.

Date of incident

Time

Employee exposed

Reported by, if not the employee exposed Phone or email for follow-up

Location

Chemical involved

Product name from the label or the Safety Data Sheet. If you are not sure, describe it.

How the exposure happened

Description of incident

What happened, what task was being done, and how much was involved.

Immediate actions taken

For example: flushed eyes for 15 minutes, moved to fresh air, contained the spill, area ventilated.

Medical treatment required

Answer yes or no only. Do not enter medical details here; the Director of Safety will follow up privately.

Reports go to the Director of Safety. Reporting is non-punitive: the purpose is to protect people and fix the cause.

Hazardous Chemical Exposure Report

Report received