ICMS-F-025-Laboratory-Accident-or-Incident-Report-Form-自2018年起使用.docx

Office of Health, Safety and Environmental Affairs 安健及環境事務辦公室 實驗室意外及事故報告表 Laboratory Accident/Incident Report Form This form is to be used to notify HSEO of an accident /incident. All mandatory fields must be completed. Completed forms should be sent to HSEO within 7 working days: * indicates mandatory information 報告人之個人資料 Details Information of Rapporteur *報告者之所屬實驗室或職位 (Dept. or Position of Rapporteur): 電郵地址 (Email): 電話號碼 (Tel No): 受傷人 Injured Person Details 受傷人中文姓名(Injured person’s name in Chinese): *受傷人英文姓名(Injured person’s name in English): 學生/員工編號 (Student/Staff no.): 性別 (Gender): 受傷人員所屬部門 (Injured person's department): 電話號碼(Tel No): 電郵地址(Email): * 職 位 (Status): ☐ 職 員 (Staff) (Visitor) ☐ 學 生 (Student) ☐外判 (Contractor) ☐訪問學者 ☐其他 (Other) 事件詳情 Event Details *事發日期(Date of event): 時間 (Time): DD/MM/YYYY: 24 小時制(24hr clock): *樓宇編號 (Building no.): 實驗室房間編號(Laboratory room no.): *導致事故/意外成因 Cause of incident/accident 固體/液態化學品 Solid/Liquid Chemicals 易燃氣體 Flammable gases   有毒氣體 Toxic gases 氫氟酸 Hydroflouric acid 氰化物 Cyanide compounds 低溫液體 Cryogenic liquid     高壓裝置 High-pressure system 高溫 High temperature  紫外線 Ultraviolet 放射性物質 Radioisotopes X-射線 X-rays 高壓電力 High voltage  實驗室動物 Laboratory animals 生物危害 Biological organisms/agents       針頭 Needle 尖銳/鋒利物 Sharp 高空工作 Working at height 其他 Others  (請注明 Please specify    ) *事件所屬級別 Scale of Severity 請根據安健及環境事務辦公室的級別分類及通報期限作相應的勾選和通報，詳情請參看第三頁 Please selected the appropriate item and notify HSEO according to the instruction from HSEO. The corresponding details is attached on page 3.  事故 (不涉及個人受傷) Incident (event not involving personal injury) 意外/事故所屬級別: 級別 0 Scale 0 (Deviation) 級別 1 Scale 1 (Incident)  意外（涉及人身傷害事件）Accident (event involving injury to a person) Hseof /024/2017 大學 格式五 Modelo 5 *報告者 (Name of Rapporteur): ML/tc/mc 05/09/2017 Office of Health, Safety and Environmental Affairs 安健及環境事務辦公室 意外/事故所屬級別: 級別 2 級別 3 Scale 3 (Accident) 級別 4 Scale 4 (Major accident) 級別 5 Scale 5 (Serious accident) *描述事故及意外事故及處理方式 *Description of Accident/Incident and Handling ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 請盡可能準確地描述發生的事情，從當時正在進行的工作活動開始。如位置不足可附加 A4 紙作附件 Please describe what happened as accurately as you can, starting with what work activity was being undertaken at the time. Addition A4 pages can be used as attachment. 防止這種事故或意外事故再次發生而採取的行動建議 Describe The Action to be Taken to Prevent a Recurrence of This Type of Accident or Incident. ______________________________________________________________________________________________________ 以下由實驗室技術員填寫 This Section is for Laboratory Technician Use 實驗室技術員簽署 Endorsed by: ______________________________ 日期 Date 實驗室技術員職稱 Job Title :_______________________________ :_______________________________ 實驗室技術員建議 Lab Technician’s Suggestion: Hseof /024/2017 大學 格式五 Modelo 5 Scale 2 (Major Incident) ML/tc/mc 05/09/2017 Office of Health, Safety and Environmental Affairs 安健及環境事務辦公室 Scale of Severity: Scale Severity 0 1 2 3 4 5 a Example(s) No property damage and no person Oxygen detector injury alarm Property damage or need to activate Chemical spill, false emergency procedure but no person injury ceiling collapse Major Person injury can be self-treatment or Incident go to clinic for treatment but no need to go to the hospital Finger cuts (手指割 傷), fall down from slippery floor Accident Person injury and/or property damage, Uncomfortable or need to go to the clinic or hospital for treatment faint during work, mice bite, needle punch Major Person injury and/or property damage Unconscious, fall accident and/or need evacuation, and need to go to the hospital and stay from height Serious Fatal or more than two persons injury Chemical explosion, accident and/or property damage, and need to go to the hospital and stay electrical shock Deviation Incident Notify to HSEOa within 48 hours Immediately 如事件級別屬於 0 級到 3 級之間，報告者需於 48 小時內以電郵或電話的方式通知 HSEO，同時此意外報告表亦應於 7 個工作天內向 HSEO 提交。如事件級別屬於 4 級到 5 級之間，報告者立即以電郵或電話的方式通知 HSEO，同時此意外 報告表亦應於 7 個工作天內向 HSEO 提交。 a If the scale of severity is between 0 -3 level, the reporter should notify HSEO within 48 hours either by email or phone, while. the accident report should be sent to HSEO within 7 working days. If the scale of severity is within 4 – 5, HSEO need to be notified either by email or phone and accident report be submitted within 7 working days. Hseof /024/2017 大學 格式五 Modelo 5 Description ML/tc/mc 05/09/2017