Laser Accident Report Form

Report a Laser Accident

We have provided the form below so you can report any laser accidents for inclusion into our database. Any personal information will remain confidential and will be used only to verify specific detail with you directly.

Our goal is to keep the laser community informed, and by doing so, prevent similar events from occurring in their other facilities.

For more information about the reporting a laser accident, please contact us via email or call an RLI representative at (800) 94-LASER.

Laser Accident Report Form

Email Address:

Description of Accident :

Injury Type:

Unknown/Other
Injury permanent
Injury temporary
Outcome unknown or indicated
No injury reported

Eyewear Specifics:

Unknown/Other

Proper Eyewear Worn

Available, Not Worn

Incorrect Eyewear

Eyewear Failure

Not worn, not available

Improper eyewear fit

Improper eyewear choice

Accident Type:

Unknown/Other

Eyewear Failure

Equipment Failure

Alignment

Bystander Injured

Laser Pointer

Environment:

Unknown/Other

Industrial

Medical

Entertainment

Education

Military

Commercial

Beam Hazard:

Unknown/Other

Eye

Skin

Non-Beam Hazard:

Unknown/Other

Electrical

Fire

Embolism

Optional Information:

Name:

Address:

Phone:

Fax:

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