Fillable Employee Incident Report 2-2018 Incident Invest Report

Fill Online, Printable, Fillable, Blank Employee Incident Report 2-2018 Incident Invest Report Form

Use Fill to complete blank online HARPER COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Employee Incident Report 2-2018 Incident Invest Report

On average this form takes 11 minutes to complete

The Employee Incident Report 2-2018 Incident Invest Report form is 2 pages long and contains:

  • 0 signatures
  • 25 check-boxes
  • 34 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Harper College

BROWSE HARPER COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Harper College
Environmental Health & Safety Procedure Manual
(Section 5 page 37-38)
See Section 5- Incident/Injury Management for additional information.
(https://www.harpercollege.edu/about/directory/ehs/occupational_health.php
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 through 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.
•
Description 19- 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.
• Cause 20- 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.
DO NOT STATE THAT THE INCIDENT WAS A RESULT OF EMPLOYEE CARELESSNESS!
Specifically define the unsafe act or condition involved that may appear to be due to carelessness
(examples: distraction, noise, stress, or other natural or unnatural factors).
• Evaluation
21. Violation of Safety Procedures - List procedures.
22. Appropriate Personal Protective Equipment (PPE) - Describe the type of PPE
23. Training –Did the employee receive appropriate training prior to the injury? Describe the type of
training and date of training received.
•
Correction 24 –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 with a copy to the Human Resources Department.
Manager, Environmental Health & Safety: Sara Gibson: sgibson@harpercollege.edu and 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 (street):
3. City & Zip:
4. Date of Birth: 5.Gender: Male or Female 6. Cell number:
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):
Health Services - Date: Occupational Clinic –Date:
Hospital/ER – 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’s Signature:
Date:
26. Supervisor’s Signature:
Date:
Send copies of completed report to Manager of Env. Health & Safety and Human Resources Rev. 2/2018
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Employee Incident Report 2-2018 Incident Invest Report

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 29 March 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document