Accident /Incident Report and Investigation Form Accident Investigations To maintain a safe and healthy campus/work environment, a thorough accident investigation should be undertaken as soon as practical after an accident or incident in order to initiate and support corrective and/or preventive actions. The Accident/incident Report and Investigation Form should be completed by the employee's supervisor with the employee. The report requires the signature of the supervisor and employee. For accidents/Incidents which require medical attention, or lost or restricted work, the report must be signed by the Divisional Vice President. Completed reports are to be sent to the Director of Human Resources.Accident /Incident Report and Investigation Form Directions: Compiete sections 4, 2, and 3 for all accidents and incidents. Accidents or incidents that require medical attention or lost or restricted work require the signature of the Divisional Vice President, Allach additional sheets as necessary. Send competed forms to the Director Of Human Resources. 4. EMPLOYEE INFORMATION Name: Social Security# = First Mi _Last Dept: Job Title: Full Time (] Part Time] Student worker] Other [1] 2. ACCIDENT! INCIDENT INFORMATION Loe’ Date of incident: 1e of incident, AMIPM check itime cannat be aeermines 1e Employee began work. AMIPN, Types ofincident [] Accident = [}_—_ Injury (check all that apply)i] illness Cl Other What was the employee doing just before the incident occurred? Describe the activity as well as the tools, equipment or materials the employee was using just before the incident. ‘What happened? Describe the incident 10f5Accident /Incident Report and Investigation Form What was the Injury/iliness? Describe what part of the body was affected and how it was affected Part of Body Affected () Head () Face (Qeyes (Ears (Neck () Shoulders () Chest () Abdomen (Soin () Back (Upper) () Back (Lower) () Buttocks 0 Fingers () Hands: (Other: How It Was Affected () Abrasion () Amputation () Bruise () Burn () Loss of Hearing () Constant Pain () Crushes () CutLaceration () Dermatitis () Dismemberment () Eye Injury () Fracture: {) Heart Attack {) Infection {) Loss of Feeling () Other: () Wrist (Arms, () Toes () Feet () Lower Leg (Knee (Upper Leg (Lungs () Nervous System {) Blood System () Skeletal System () Digestive System {) Reproductive System () Skin ) Industrial liness-Repeated Exposure } Industrial Iliness-One Time Exposure ) Inflammation } Concussion \Contusion Loss of Sight Poisoning Puncture Strain/Muscle Pull Swelling Trauma ( ( ( ( ( ( ( ( ( ( ( ( Unconsciousness y } } } ) } ) ) ) ) What object or substance directly harmed the employee? Examples, “concrete floor’, “chlorine”, or “grinding wheel fragments". If this question does not apply to the incident, leave it blank. 20f5Accident /Incident Report and Investigation Form Did the employee receive medical treatment? Yes[_] (list below) Nol] Medical Factity: Attending Physician/Surgeon: ( Treated and released [Hospitalized Was this activity part of the employee's regular job? Yes] No[] Did the employee lose any work time after the day of the incident? Yes} NoL] Ifyes, the date time away from work began Date employee returned to work Clcheck i date cannot be determined at tis Te Did the omployee die as a result of this incident? Yesi] Nol] Were there any witnesses or other employees directly involved? Yes[_] list below) NoL] Name Phone # Name Phone # Were any immediate corrective actions taken? Yes{_] (describe below) Nof] 3. ACCIDENT/ INCIDENT INVESTIGATION Root causes and contributing factors: (The attached checklist may be used as a guide if needed.) 1. 2. 3. Why did each of the above items exist (Link #1 with #1 root cause, etc.) 1. 2, 3015Accident /Incident Report and Investigation Form Corrective Actions (List what long term actions are being taken as a result of this accident.) 1 ‘Target Completion Date ‘Target Completion Date, ‘Target Completion Date, Employeelinjured Party Employeelinjured Party Namo Bate Signature (print) Supervisors Signature ‘Supervisor's Name (print) Dato The signature of the Divisional Vice-President is required for accidents resulting medical attention, or lost or restricted work. Division Vice President Division Vice President Name Date Signature (print) For internal use Signature: Bate Signature Date: Director of Human Resources. Manager of Regulatory Affairs & Risk Mgt. Page 4 of 5Accident /Incident Report and Investigation Form ANALYSIS CHECKLIST Potemtat Causes (check al that apaly) 6. Malerale Handiing/Process Operationsdaintensnce 1 2 3 4 5 Mechanical Controls (Guerdés(Devieos) ()Were not designed to prevent his crcumstance. (O)Were avaiable but notin pace a time of sccident (O) Were in place but id not work (Were avaiable but were intentionally not used at lie of siden ()Were not avalbte. (Warning devices dé not function, (O)Waming deviess functioned but were ignored, (Not apptcable. Desian/Conetruction ()Poorjob layout or design. (Adequate apace ie nel proved for propae postoning, (Altnecessory equipment to complete the job was nol avaiabe. (hinadequate ventiaton, lumination,surtacing, is ol proves, (O tmproper to! used. (OINotappkcabe. Inspection pronrarDstectve Equipment () Equipment wes not adequately inspectod or was defective, ( Processestoperatons were nol adequately reviewed. (nspectors were not adequately trained to recognize the nazar (} Preventative maintenance performed oi net ‘address ths ecumstance, (inspections were not frequent enough to detect this problem (0) Problem was recognized, but work order was ‘ever writen (ONot applicable Pol struct (There isnot a writen policy or work instruction ‘covering this circumstance, but there should be. {O There is urteninsvetion or polly, but hey were not followed (0 There i a policy, butt does not conecty accross ths exeumstanee (ONot applicable. ()Poor housekeeping. (insecure storage (Poor sumination. (0 improper veatiation (O Lesking contsinesfipingtpomps (enproper containers. 10. Sofs () Mixing or using the wrong chemical (Over exertion in handling containers (Improper opening or losing procedures. (Fall to follow lockout, confined space, hot ‘Work, or en-tne leaking procedures, (overloading equipment or process, (Not apptcabe. Similar Accdente/Work Practces/Condtions () Similar accidents have occured without investigation () Similar accidents or poor work practices have ‘ccutted without coreeive action {0 Employees/managerent have tolerated the Unsafe practices ar conltion(s), {O)Not applicable, Tesining {0 Employee was not adequately tained in safe work roceduresiptces, ules, including chemical hazards {Employee was rot adequately trained in hazard ‘eentieaton, (O Employee was not adequately trained in Jebfequipment epecitc operation. ( Superisor was not adequately tained (Employee was tained, but dt nat lize learned slisnfomation Human FactouBshavior () Not wearing PPE (see tem #4) (0 Designfprocedutes donot interface well with human characteristics, Make job more eifcut to complete, (Glee creates too much physica stress. (dod creates too much mental sess, (inadequate tine to adequately complete this jo, (0 Problem was pointed out to members of ‘management bul wae never correcta () Emaloyee was nt periodically observed on the ob, () dob s deslgned such that is it easir to perform it unsafe (0 eb does no tthe person, (Causes awkwant postures on postoning. (0b overloads employee vith information. {0 Job requites employee to work too rapidly. (O Employee gots a reward to ish quiet, ‘Supervision (Q)Wiork site inadequately supervised (O Necessary supporive services wore not avaliable, (OVNetapplcabte.