Fillable INCIDENT INVESTIGATION FORM (Pennsylvania State University)

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INCIDENT INVESTIGATION FORM (Pennsylvania State University)

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The INCIDENT INVESTIGATION FORM (Pennsylvania State University) form is 2 pages long and contains:

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  • 47 check-boxes
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Country of origin: US
File type: PDF

U.S.A. forms for Pennsylvania State University

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Supervisor Name:
Signature:
Description of Pictures Taken:
Body part injured and type of injury (be specific):
If it is a Near Hit, descibe the potential injury/damage:
Weather conditions at time of accident:
Visibility/Lighting (ex. poor, work lights, etc.):
Type and condition of floor surface (ex. concrete, wet):
PPE required for job:
Was PPE being utilized?
INCIDENT INVESTIGATION FORM
Directions for Completion:
1. Notify Safety Specialist within 24 hours of incident(Employee Injury, Near Hit, Property Damage).
2. Complete and
submit this form to the designated Safety Office within 3 working days of the accident/Incident.
3. Please remember to sign and date the form.
4. Make five copies of this form for any Lost Time Injury Investigations.
Accident Data/Contributing Factors
Yes No
Employee Injury
Near Hit Incident
Property Damage
Employee Data
Employee Name: ______________________________________________________ Today's Date: ____________________
Department: _________________________________________________ Job Title: _________________________________
Work Area: __________________________________________________ Shift: ____________________________________
Length of Employment at PSU: _________________________________ Full Time Part Time Wage
Location of Accident (Building, Room Number): _____________________________ Date of accident: _________________
Time of accident: ______________ AM PM Claim Number: _______________________________________________
Detailed narrative of how incident occurred:
What was employee doing just prior to accident (job task, include any tools or machinery used):
Physical Plant Safety Office
103 Physical Plant Building
University Park, PA 16802
Auxiliary & Business Services Safety Office
127 Johnston Commons
University Park, PA 16802
Submit completed form to one of the following
locations:
click to sign
signature
click to edit
Direct/ Immediate Causes (supervisor complete)
Defective Tools/ Equipment Unaware of potential hazard Unauthorized equipment use
Unsafe work Procedures Lack of safety devices Guard removed/ guard needed
Insufficient procedures Not employees normal job Poor housekeeping
Not following procedures Improper use of tools Violated safety rule
Improvising/ shortcuts Proper tools not available Not wearing proper equipment
Root Causes
Employee unaware of hazard Failure to recognize unsafe act Equipment maintenance
Complex procedures Poor attitude Weather Condition(Rain, Snow)
Unclear instruction Personality conflict Excessive production pressure
Inadequate training Lack of training Communication error
Inadequate comprehension Job design/ workstation layout Lack of employee cooperation
Lack of skill/ knowledge Lighting Other, please explain:
Recommended Engineering control, Training, or Program/policy change:
Remedial training given:
Was a work order or a project request submitted for solution(s)?
Please provide details of request including job/project number and deadline for completion:
Wha
t action was or should
be ta
ken to prevent recurrence?
Yes No If no, explain:
Date:
Date:
Corrective actions completed?
Investigated by:
Reviewed by:
Corrective Actions
Causes
PLEASE CHECK ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS
Phone#
Was there any damage to property or equipment?
Explain:
Name(s) of witness(es):
Name(s) of witness(es): Phone#
Yes No
____________________________
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INCIDENT INVESTIGATION FORM (Pennsylvania State University)

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Completed 25 May 2022

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