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� <br />KAISER PERMANENTE MEDICAL OFFICE <br />BTO[IKTON <br />REPORT OF HA7ARDOUS MATERIAL SPILL <br />In the event of a 'spill' of a hazardous material, <br />including a liquid, solid or gas~ the who discovergA the <br />spill and/or was involved in the clean-up needs to complete this form. <br />^ The immediate supervisor needs to review the report, and may need to <br />add in further information (e.g. how the material was disposed of <br />after the clean-up). The report is to be forwarded to the facility's <br />Safety Officer within 24 hours of the spill. <br />Name of Person who discovered the spill: <br />Date of spill: �Time discovered: � <br />Exact location of spill: <br />What was the material which spilled? <br />How did you discover it (what happened)? ' <br />Whom did, you moti*fy? <br />Describe what stops were taken for of the ' <br />material. <br />Did you refer to aMaterial Safety Data Sheet (MSDS) to assist you in <br />safely cleaning up the material? Disposingof the Material? <br />NO: YES: <br />Was there any injury ada result of the spill or clean-up? <br />NO: YES: I+ so: please describe: <br />(NOTE - Supervisor: For anjury, be sure that an <br />'Employee's Report bfIndustrial Injury' form and an 'Accident Inves- <br />tigation' form are completed. If a <br />member was injured, be sure an 'Unusual Occurrence Report' form is <br />completed.) <br />COMMENTS: <br />Report completed by: <br />Report reviewed by: <br />Date: <br />Date- <br />***** RETURN COMPLETED FORM TO THE SAFETY OFFICER ***** <br />