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Chemical Spill or Contamination Follow-up Report

This form is to provide follow-up documentation for chemical spills or other contamination events. It does not substitute for immediate notification of emergency personnel in the event that you are currently experiencing a major spill or potential injury or exposure of personnel.

Please complete the following information and submit it to EHS by clicking the submit button at the bottom of the form.

First Name:
Last Name:
Phone Number:
E-Mail:
Lab Group or Department:
Date and Time spill occurred or was discovered: Date
Time
 
Location of spill or contamination
Building/Location:
Room Number:
 
Description of spill or contamination
Name of material spilled (if known):
Estimated amount spilled (include units):
Approximate area covered by spill (include units):
Any personnel contamination?
Any contamination of soil or water?
 
Narrative of event: Please provide a brief statement describing what happened, any cleanup steps that were taken, any injuries or exposures, and what was done with contaminated supplies or cleanup waste.