Mercury Safety Products - Sample Hospital Admin Forms

Two types of form are used: five copies of the Incident Report Form are kept in the spillage kit. After each spillage, a report form is sent back to the Administrator, who monitors the use of each kit, which can be used up to five times.

**Sample Incident Report Form**
Date of report Reported by (name)............................... Job title................................... Ward name or room number.................................... Spillage kit serial number................................... Expiry date...................................... Description of incident: Estimated time elapsed before spillage was dealt with................................................... Please return completed form to [Mr Sanderson] in the [Estates Office], from where spares and replacement items for the spillage kits can be obtained. Phone [123456] in the event of difficulty.

We suggest:
Five copies of this form to be issued with each Mercury Spillage Kit, folded in half and kept in the lid with the instructions.

**Sample Administrator's Form**
Location - Ward Name or Room Number	Spillage Kit Serial Number	Expiry Date	No. of times kit may be used before replacement
A&E	02334	Jun 2001	5 4 3 2 1
A&E	02335	Jun 2001	5 4 3 2 1
Ward 1	02336	Jun 2001	5 4 3 2 1
Ward 2	02337	Jun 2001	5 4 3 2 1
Laboratory	02338	Jun 2001	5 4 3 2 1
Outpatients Clinic	02339	Jun 2001	5 4 3 2 1
Childrens' Ward	02340	Jun 2001	5 4 3 2 1
Consultants Suite	02341	Jun 2001	5 4 3 2 1
Pharmacy	02342	Jun 2001	5 4 3 2 1
Stores	02343	Jun 2001	5 4 3 2 1
Repair Workshop	02344	Jun 2001	5 4 3 2 1

Each time a spillage kit is used, strike out one 'life' in the final column. This will tell you when individual kits require replacement or replenishment with spares. You will also be able to detect areas of higher risk and target these for training.

Last Updated February 1998.