CSULB COLLEGE OF NATURAL SCIENCES AND MATHEMATICS

Environmental Health and Safety Program

DATE OF INCIDENT:                                                                                                       TIME:

LOCATION:. 

INCIDENT DESCRIPTION : 

NAME(S) OF IMPACTED PERSON(S): 

 
(E)" For Employee or "(S)" for student must follow name(s)

NAME(S) OF RELEVANT WITNESSES: 

INDIVIDUAL(s) IN CHARGE OF AREA/OPERATION: 

RESPONSIBLE DEPARTMENT:                                              DATE FORM INITIATED:

__________________________________________________________________________________________

(To be completed only by administrative and/or EH&S personnel only)

INVESTIGATED BY:

INVESTIGATION DATE(S):

CORRECTIVE MEASURES TAKEN:

Report Received at Department by: 

Date: 

FORM DISTRIBUTION: Original: Appropriate administrator (Usually Dept. Chair)
Copy: CNSM Dean & CNSM Safety Office