For Human Resources Use Only
HR Review:
Safety Log#:
Dept. Org#:
OSHA Log#:
EMPLOYEE ACCIDENT/INCIDENT ANALYSIS FORM
(Management should complete this form promptly with the impacted employee- Please PRINT)
When completing the form, please be as detailed as possible
Employee/Department Information
(To be completed by Employee or Manager)
Last Name
First Name
L#
Employee Department
Home/Cell Phone
Manager
Manager Department
Time Employee began Work on Date of Incident
2. Accident/Incident Information
(To be completed by Employee or Manager)
Near Miss
First Aid
FILE 801, IF BOXES BELOW ARE CHECKED
Medical Care
Time Loss
Fatal
Date of Accident/Incident
Time of Accident/Incident
Date First Reported
Time First Reported
Accident/Incident Location:
Describe Injury (Nature of Injury/Part of Body)/Incident:
Describe Accident/Incident Fully (What happened and why?):
Witness(es):
Phone Number (s):
The purpose of this form is to assist Human Resources and the Safety Committee to identify safety issues on campus. It is very
important that you be as detailed as possible when completing this form. Please submit additional pages if needed
3. First Aid/Medical Treatment Given
(To be completed by Employee or Manager)
Describe First Aid/Medical Treatment given(if any):
Was a prescription given? YES NO
By Whom?
When?
If treatment was given away from the College, where was it given?
Name of Physician/Health Care Professional
Facility Name
Street
City
State
Zip
Was Employee treated in an emergency room?
YES NO
Was employee hospitalized overnight?
YES NO
4. Factors (To be completed by Manager) Please complete each area below with as much detail as possible. When
completing each section, use the descriptors to help identify factors that may have contributed to the accident/incident
Management: Do we have?
Employee: Was the employee?
Policy Enforcement
Hazard Recognition
Supervisor Training
Following Procedure
Trained
Previous Injury
Corrective Action
Proper Resources
Job Safety Training
Mental/Physical Ability
Safety Attitude
Proper Equipment Use
Adequate Staffing
Safety Observation
Other:
Using Short Cuts
PPE Worn
Other:
Equipment: Do we have?
Environment: What about:
Proper Tool Selection
Tool Availability
Maintenance
Physical conditions
Temperature
Noise
Visual Warnings
Guarding
Other:
Biological/Chemical
Weather
Terrain/Lighting
Vibration/Ventilation
Ergonomics
Other:
Additional Factors: Faulty Equipment Non-Employee Prior Injury Late Reporting Off-the-Job Injury
5. Counter Measures/Best Practices (To be completed by Manager)
Please complete area below with as much detail as possible.
How do we correct areas identified as factors in causing the incident/accident?
Who will make changes and when will the changes be completed? Use other side of form if needed. Consider immediate
and long-term corrective actions.
Counter Measure
Who?
By When?
Work Order #: _________________ (If counter measure includes a work order, please indicate work order #)
6. Signatures
Completed by: (Please print)
Title:
Employee Signature:
Date:
Manager Signature:
Date:
Send to Human Resources when Completed Revised: 5/22/14
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