MSU Denver Incident Report 05/2017
Report
Initia
ted By:
Phone
Number:
Date
& Time:
Type of Incident – Check all that Apply
Injury/Illness
Spill
Fire
Flood
Sewer Release
Air Emission
High Loss Potential
(near miss)
Property Damage
Other
General Incident Information
Campus: Building: Room:
Date: Time:
If outside, describe location:
Hospitalization/Clinic Visit Required Yes No Emergency Services Response Required Yes No
Detailed Incident Description
Hazardous Material(s)
Involved:
People Involved in the Incident (e.g., injured, observed, present, exposed/potentially exposed)
Name:
Position:
Injured? Yes No
(if yes, fill out “Injury follow-
up” section)
Name:
Position:
Injured? Yes No
(if yes, fill out “Injury follow-
up” section)
Name:
Position:
Injured? Yes No
(if yes, fill out “Injury follow-
up” section)
Injury Follow-up
Name:
Medical evaluation recommended?
Yes No
Transported to:
Name:
Medical evaluation recommended?
Yes No
Transported to:
Name:
Medical evaluation recommended?
Yes No
Transported to:
Actions Already Taken by those Involved in the Incident
Cause Analysis
Immediate Causes What Actions and Conditions may have contributed to this event? (see examples below)
Basic CausesWhat specific personal or job Factors contributed to this event, if applicable? (see examples below)
EXAMPLES OF IMMEDIATE CAUSES
Substandard Actions
1. Operating Equipment
without Authority or
Supervision
2. Failure to Warn
3. Failure to Secure
4. Making Safety Devices
Inoperable
5. Removing Safety Devices
6. Failure to Use PPE or
Proper PPE
7. Using Defective Equipment
8. Under Influence of
Alcohol/Drugs
9. Horseplay
Substandard Conditions
1. Guards or Barriers
2. Protective Equipment
3. Tools, Equipment, or Materials
4. Congestion
5. Warning System
6. Noise Exposure
7. Fire and Explosion Hazards
8. Poor Housekeeping
9. Exposure to Hazardous Materials
10. Extreme Temperature Exposure
11. Illumination
12. Ventilation
13. Visibility
EXAMPLES OF BASIC CAUSES
Personal Factors
1. Capability
2. Knowledge
3. Skill
4. Stress
5. Motivation
Job Factors
1. Supervision
2. Engineering
3. Purchasing
4. Maintenance
5. Tools/Equipment
6. Work
Standards
7. Wear and Tear
8. Abuse or Misuse
Would you like EHS to conduct a risk assessment or further training? Yes No
Phone:
Phone:
Phone:
Yes
No
Metropolitan State University of Denver
MSU Denver Incident Report 05/2017
Action Plan (to be completed by EH&S)
Corrective ActionsWhat has been or should be done to control the causes listed? Include Management programs (see
examples below) if applicable.
Action
Person
Responsible
Target date
Persons Performing Investigation
Name: Signature: Date:
Name: Signature: Date:
Witnesses (list):
Management Review
PI/Lab Coordinator Name: Signature: Date:
Comments:
EHS Lead Name: Signature: Date:
Comments:
Risk Management Name: Signature: Date:
Comments:
Note: Attach additional information as necessary
MANAGEMENT PROGRAMS FOR CONTROL OF INCIDENTS
1. Leadership and Administration
2. Management Training
3. Planned Inspections
4.
Task Analysis and Procedures
5. Task Observation
6. Emergency Preparedness
7. Organizational Rules
8. Accident/Incident Analysis
9. Personal Protective Equipment
10. Health
Control
11.
Program Audits
12. Engineering Cont
rols
13. Personal
Communications
14.
Group Meetings
15.
Hiring and Placement
16. Purchasing
Cont
rols
17. Employ
ee Training
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