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ATTACHMENT A <br /> KAISER PERMANENTE MEDICAL OFFICE <br /> STOCk:TON <br /> REPORT OF HAZARDOUS MATERIAL SPILL <br /> INSTRUCTIONS: In the event of a -spill ' o4: a. hazardous material , <br /> including a l. icai_iid , soli_d� or gas, the employee(s) who discovered the: <br /> G?i .11 andii±r l+Ji1I i't <br /> l ''Y --Iv[_d in j..l-ie 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:. AM/PM <br /> Exact location of spi 11: <br /> What was .the material which spilled? <br /> How did you discover it (what happened) ? <br /> Whom did you noti'f y? <br /> Describe what steps were taken for removal and disposal .of the <br /> materials <br /> Did von� refer to a Material Safety Data Sheet (MEDS) to assist you in <br /> safely cleaning up the material^ Disposing of the Material? <br /> NO- YES: <br /> Was there any injury as a result of the spill or clean-up`"' <br /> NO: YES: If so please describe: <br /> (NOTE - Supervisor: For an employee injury be sure that an <br /> "Employee '.s .Report of Industrial Injury.' form and an 'Accident hives- <br /> tigation ` form are completed. If a pagt,ient . visit or registry staff <br /> member was i n i+.gyred , be sure an 'Unusual Occurrence Report ' form is <br /> completed, <br /> -COMMENTS: <br /> Report completed by: Date: <br /> Report reviewed by: Date: <br /> ***** RETURN COMPLETED FORM TO THE SAFETY OFFICER *# <br />