"Accident/Incident Report Form - University of Alaska Fairbanks"

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University of Alaska Fairbanks
Accident/Incident Report (personal injury)
To report an automobile accident, do not use this form, please go to:
http://www.alaska.edu/risksafety/g_forms-library/alinsured.pdf -fill out form
____________________________________________________________
SECTION I: EMPLOYEE INFORMATION
(completed by employee)
Name________________________________________________________
Sex _____
______
Date of Birth_______________________
(Last, First, M)
Male
Female
Home Address_____________________________________________________________ Home Phone____________________________________
Date Employed_____________
Supervisor’s Name_______________________________
Department___________________________________________________________________________
Work Phone________________________
(Normal department, even though working in another department at time of incident)
_____________________________________________________________
SECTION II: INCIDENT (completed by employee)
Job title at time of incident______________________________________________________________ Experience in this job_____________________
Department where incident occurred______________________________________________________ On company premises? Yes ___ No___
Exact location of incident_______________________________________________________________________________________________________
How did the incident occur? Describe events that resulted in incident. What happened? How did it happen? What were you doing? (Be specific)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Describe injury/illness in detail. Indicate body part(s) affected. (Examples: Twisted left knee with excessive swelling, cut right index finger at second
joint, fracture of ribs, nauseous from inhaling fumes, etc.)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Name the object/substance that directly injured employee. (Examples: lathe, chlorine gas, 50 pound box, etc.)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
)_____________________________________________________________________________________________
Name(s) of witness(es
Severity of injury: ___None ___First Aid ___Medical treatment
Date of incident_____________________ Time_____:_____ __AM __PM
Date employer knew of accident_____________________________
Additional Employee Comments:
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Fill in the above information and print the two page form. Forward to your supervisor for completion of
section III
University of Alaska Fairbanks
Accident/Incident Report (personal injury)
To report an automobile accident, do not use this form, please go to:
http://www.alaska.edu/risksafety/g_forms-library/alinsured.pdf -fill out form
____________________________________________________________
SECTION I: EMPLOYEE INFORMATION
(completed by employee)
Name________________________________________________________
Sex _____
______
Date of Birth_______________________
(Last, First, M)
Male
Female
Home Address_____________________________________________________________ Home Phone____________________________________
Date Employed_____________
Supervisor’s Name_______________________________
Department___________________________________________________________________________
Work Phone________________________
(Normal department, even though working in another department at time of incident)
_____________________________________________________________
SECTION II: INCIDENT (completed by employee)
Job title at time of incident______________________________________________________________ Experience in this job_____________________
Department where incident occurred______________________________________________________ On company premises? Yes ___ No___
Exact location of incident_______________________________________________________________________________________________________
How did the incident occur? Describe events that resulted in incident. What happened? How did it happen? What were you doing? (Be specific)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Describe injury/illness in detail. Indicate body part(s) affected. (Examples: Twisted left knee with excessive swelling, cut right index finger at second
joint, fracture of ribs, nauseous from inhaling fumes, etc.)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Name the object/substance that directly injured employee. (Examples: lathe, chlorine gas, 50 pound box, etc.)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
)_____________________________________________________________________________________________
Name(s) of witness(es
Severity of injury: ___None ___First Aid ___Medical treatment
Date of incident_____________________ Time_____:_____ __AM __PM
Date employer knew of accident_____________________________
Additional Employee Comments:
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Fill in the above information and print the two page form. Forward to your supervisor for completion of
section III
____________________________________________________________
SECTION III: SUPERVISOR’S REPORT OF INCIDENT (completed by employee’s supervisor)
When were you notified of injury/illness? Date________________________________ Time ______:_______ ____AM ____PM
Do you agree with the employee’s incident information on side one? ____Yes ____No (provide comments below)
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
What could have been done to prevent this accident?____________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
What action have you taken to avoid any reoccurrence?__________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Supervisor’s name________________________________________________ Shop/Department________________________________________________
Supervisor Signature___________________________________________________________________ Date ______________________________________
Forward to EHS&RM via intercampus mail Box 8145, or fax at 474-5489
_______________________________________________________________
SECTION IV: INVESTIGATION (completed by Safety Officer)
Background Information of Incident (provided by employee) validated ___Yes ___No (If no, provide comments_____________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Account of Accident (what happened-sequence of events, extent of damage, type of accident/hazard, agency or source of energy/hazardous material. etc.)
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Analysis of Accident (How/Why—Direct, indirect, and basic causes) _________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Recommendations to Prevent a Recurrence ____________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Safety Officer Name_______________________________________________________________
Safety Officer Signature________________________________________________________________________ Date_______________________________
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