"Injury and Incident Investigation Report Template - Florida Polytechnic University"

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Injury and Incident Investigation Report
(10/12 rev 1)
This report is to be completed by the supervisor with the assistance of the affected employee. Answer All Questions
Employee Name
Date of Accident
Department
Work Phone #
Nature of Injury/Exposure
Description of Event: What was employee doing just before and at the time of the incident? What happened or what work conditions contributed
(e.g. repetitive motion during pipetting in laboratory, slipped on water on floor in front of ice machine)?
Factors that contributed to incident/injury – Please check all that apply.
Hazard
Communication
Facilities/Equipment
Not recognized/identified
Breakdown in verbal communication
Personal protective equipment (See below)
Identified but not addressed
Breakdown in written communication
Faulty equipment
Inadequate repair
Confusion after communication
Poor/inadequate maintenance
Other ____________________
Inappropriate use
Work Procedures
Missing guards
None developed
Obsolete/antiquated equipment
Not followed
Other
Inadequate design
Partially followed
Weather/temperature
Ergonomic factors
Not understood
Extended work hours
Equipment failure
Not appropriate
Worker fatigue
Trip hazard
Not communicated
Physical overexertion
Slip hazard
Other ___________
Work in elevated area
Struck by
Chemical Use
Other ______________________
Training & Certification
Biological agent
Insufficient training
Radiation
PPE Requirements
Circumstances not covered
Electricity
Req. Used Type
Ineffective training
Mechanical
Eye
Worker not authorized
Face
Outdated Training
Hearing
Skin/Glove
Foot
Other
Prevention – Describe all corrective actions taken to prevent recurrence (e.g. initiated work order for sidewalk repair, retrained
workers on use of eye protection, installed ergonomic keyboard/mouse tray).
Action:_____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Person responsible: _____________________________________________________________Expected Completion Date _______________
Action:_____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Person responsible: ______________________________________________________________Expected Completion Date ______________
Supervisor
Name ___________________________________________
Title_________________________________ Phone ________________
Signature
___________________________________________________ Date ________________________
Email
_______________________
Employee Name _____________________________________________
Title_________________________________ Phone _______________
Signature (if available) ________________________ Date ________________________ Email _______________________________
Witness Name:______________________________Signature ______________________________________________
Supervisor/Director Name:______________________________Signature ______________________________________________
Please send completed forms as well as any questions or comments to the Enviromental Health and Safety Department at
ehs@flpoly.org
Injury and Incident Investigation Report
(10/12 rev 1)
This report is to be completed by the supervisor with the assistance of the affected employee. Answer All Questions
Employee Name
Date of Accident
Department
Work Phone #
Nature of Injury/Exposure
Description of Event: What was employee doing just before and at the time of the incident? What happened or what work conditions contributed
(e.g. repetitive motion during pipetting in laboratory, slipped on water on floor in front of ice machine)?
Factors that contributed to incident/injury – Please check all that apply.
Hazard
Communication
Facilities/Equipment
Not recognized/identified
Breakdown in verbal communication
Personal protective equipment (See below)
Identified but not addressed
Breakdown in written communication
Faulty equipment
Inadequate repair
Confusion after communication
Poor/inadequate maintenance
Other ____________________
Inappropriate use
Work Procedures
Missing guards
None developed
Obsolete/antiquated equipment
Not followed
Other
Inadequate design
Partially followed
Weather/temperature
Ergonomic factors
Not understood
Extended work hours
Equipment failure
Not appropriate
Worker fatigue
Trip hazard
Not communicated
Physical overexertion
Slip hazard
Other ___________
Work in elevated area
Struck by
Chemical Use
Other ______________________
Training & Certification
Biological agent
Insufficient training
Radiation
PPE Requirements
Circumstances not covered
Electricity
Req. Used Type
Ineffective training
Mechanical
Eye
Worker not authorized
Face
Outdated Training
Hearing
Skin/Glove
Foot
Other
Prevention – Describe all corrective actions taken to prevent recurrence (e.g. initiated work order for sidewalk repair, retrained
workers on use of eye protection, installed ergonomic keyboard/mouse tray).
Action:_____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Person responsible: _____________________________________________________________Expected Completion Date _______________
Action:_____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Person responsible: ______________________________________________________________Expected Completion Date ______________
Supervisor
Name ___________________________________________
Title_________________________________ Phone ________________
Signature
___________________________________________________ Date ________________________
Email
_______________________
Employee Name _____________________________________________
Title_________________________________ Phone _______________
Signature (if available) ________________________ Date ________________________ Email _______________________________
Witness Name:______________________________Signature ______________________________________________
Supervisor/Director Name:______________________________Signature ______________________________________________
Please send completed forms as well as any questions or comments to the Enviromental Health and Safety Department at
ehs@flpoly.org