Fillable Employee Incident Report

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Employee Incident Report

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Harper College
Environmental Health & Safety Procedure Manual (Section 5 page 37-38)
See the Environmental Health & Safety Procedure Manual, Section 5- Incident/Injury
Management for additional information. (http://hip/as/plant_aux/)
The injured employee’s supervisor shall complete the following “Incident Investigation Report”. If you have
questions about the form or Workers’ Compensation please contact Sara Gibson, Manager of Env. Health &
Safety x6923 or sgibson@harpercollege.edu .
E. Completing the Investigation Report
Once the investigation process is complete and the facts are known, preparing the report should not be
difficult. Follow the steps to complete the Incident Investigation Report.
Report Questions 1 - 14 are self-explanatory but are important for administrative and follow-up reasons.
Injury
15. Incident Type: This explains the type of incident being investigated, i.e., fall from ladder, stepped on
nail, electrical shock, struck by a vehicle, fire, lifting materials, etc.
16. Part of Body Injured: arm, leg, etc.
17. Lost Time: This is time lost due to an incident where the employee could not return to work
immediately.
18. Incident Treatment: This is where the employee was sent for treatment.
19. Description: Describe in complete detail what happened ask open-ended investigative questions
such as where-when-why-how. Describe the activity the worker was involved in, who else was involved
(list witnesses), what materials, equipment or tools were involved (MSDS, Serial, and Model Numbers).
Describe the types of protective equipment required and how actually used.
20. Cause: This is the most critical question in the investigation because it identifies the act or
condition requiring change that will control recurrence of like accidents. The investigator needs to get
beyond just the employee involved; evaluate all of the management operational controls that could be
responsible for the accident.
SPECIAL NOTATION: DO NOT STATE THAT THE INCIDENT WAS A RESULT OF EMPLOYEE
CARELESSNESS! SPECIFICALLY DEFINE THE UNSAFE ACT OR CONDITION INVOLVED THAT
MAY AT FIRST APPEARS TO BE CARELESSNESS, I.E. DISTRACTION, NOISE STRESS, HEAT,
COLD, OR OTHER NATURAL AND UNNATURAL FACTORS.
Evaluation
21. Violation of Safety Procedures: List procedures.
22. Appropriate Personal Protective Equipment: Describe the type of Personal Protective Equipment.
23. Training: Did the employee receive appropriate training prior to the injury? Describe the type of
training and date of training received.
24. Correction: Based on the information developed through previous questions, clearly define steps
that must be taken to prevent similar accidents in the future. Solutions that permanently fix the problem.
Routing The Supervisor, should review the incident investigation report with the employee for
completeness and accuracy, both should sign and date the report, and send it to Sara Gibson, Mgr. Env.
Health and Safety (Phy. Plt.) with a copy to the Human Resources Department
If sending electronically send to:
o Manager, Environmental Health & Safety: Sara Gibson: sgibson@harpercollege.edu
o Copy Human Resources: Jodie Olsen: jolsen@harpercollege.edu
Harper College
Environmental Health & Safety Procedure Manual (page 38)
5.3 INCIDENT INVESTIGATION REPORT (see instructions on page 37 of EH&S Manual)
1. Name of Employee:
2. Home Address, City:
3. Employee #:
4. Date of Birth:
5.Gender: Male or Female
7. Marital Status: Married, Single or Divorced
8. Department:
9. Classification: Classified, Super Con., IEA/NEA, ICOPS, Pro-Tech, Admin. Faculty Other
10. Check: Part time or Full time
11. Shift : 1st 2nd 3rd Other: AM/PM To AM/PM
12. Date of Incident: Time:
13. Location of Incident:
14. Was the activity the employee was involved in, part of, or within the employee’s regular job duties? Yes No NA
INJURY
15. Incident type:
16. Body part injured:
17. Did the incident result in lost time? Yes No
If yes last day worked:
18.Incident treatment and date (check more than one if necessary):
NCH - Date:
Emergency Room - Date:
Personal Physician - Date:
19. DESCRIPTION (Write a detailed description of what and how the incident happened, including witnesses.)
20. CAUSE (Identify unsafe acts or conditions–contributor factors–base cause–lack of management operational controls)
21. EVALUATION: Were there any violations of safety procedures? No Yes , If yes, explain:
22. Was appropriate personal protective equipment being worn/used? NA No Yes, If yes, explain:
Describe type of equipment:
23. Did the employee receive appropriate training prior to the injury? NA No Yes
Describe Training & Date:
24. CORRECTION (How could this incident be avoided in the future? Describe changes or improvements in equipment,
procedures, training and/or personal protective equipment needed.)
25. Employee Signature:
Date:
26. Supervisor’s Signature:
Date:
Send copies of completed report to Manager of Env. Health & Safety and Human Resources Rev. 8/18
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Employee Incident Report

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Completed 29 March 2020

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