Fillable SCU EMPLOYEE INCIDENT REPORT FORM (Santa Clara University)

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SCU EMPLOYEE INCIDENT REPORT FORM (Santa Clara University)

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SCU EMPLOYEE INCIDENT REPORT FORM
Complete within 24 hours and email to Sean Collins, the EHS Director, at spcollins@scu.edu or fax
at 408-554-4734
IMPORTANT: Any spills/releases to the environment, injury resulting in death, permanent disfigurement,
dismemberment, or hospitalization expected to last more than 24 hours must be reported to EHS
immediately (408‐554‐5078 or x 5078).
For instructions on other required reporting of workplace injury/ illness, contact the Department of Human
Resources
.
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PART 1: PERSONAL IDENTIFICATION
Employee Group
Name (
Last, First
) Department Employee
Student employee
For incidents involving students,
visitors, and other third‐parties,
complete the SCU Incident Form 2
Job Title Work Phone Home Phone
Employee Start Time Employee Work Days
Supervisor Name (Last, First) Title Work Phone
Work Schedule:
Full‐time
Part‐time
Bargaining Unit:
Yes
No
PART 2: INCIDENT DESCRIPTION
Date of Incident Time of Incident Location of Incident (Street address or Bldg name, Room# )
Yes
Æ
employee
injury/ illness?
No
Description of Injury/ Illness (type of injury/ illness & body part, e.g. sprained rt. ankle, severe cut on left thumb):
Resulted in spill
Yes
Æ
or release to
No
Description of spill or release (quantity, duration, location, extent of spill/release):
Incident details‐‐
Witness Name(s)/ Ph. #(s):
•
Specific task being performed at
time of incident:
•
Step‐by‐step events leading up
to the incident:
•
Equipment/ tools involved:
•
Materials being handled:
•
Unusual condition(s):
•
Other relevant details:
Continued on attached sheet (page 3):
Was this an injury caused by an animal (i.e. bite,
Yes
Æ
scratch)?
No
If yes, indicate animal species:
Medical evaluation:
Conducted at SCU contracted medical facility
Conducted at other medical facili
ty:____________
Deemed
unnecessary by employee
Date of initial medical evaluation:
Important: For instructions on other
required reporting of workplace injury/
illness, contact Human Resources.
Name & Ph# of treating physician:
Employee Signature* Date
* Signing of this form does not constitute acceptance of individual fault
‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Give to Supervisor to complete next page ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
SCU Employee Incident Form (11/2017) Page 1 of 3
Page 2 of 3
SCU Incident Form (11/2017)
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PART 3: ADDITIONAL INCIDENT INFORMATION
Supervisor Comments (additional information on nature of incident details, etc.)
Is this a “sharps injury” (i.e. needlestick, cut, or abrasion) with
Yes
Æ
an object that may have been contaminated with blood or
No
other potentially infectious material?
If yes, Cal/OSHA requires additional reporting‐ contact EHS at
554‐5078.
PART 4: POSSIBLE CAUSAL FACTORS
Process/ environment‐related: (Check all that possibly apply)
Housekeeping Workstation/ area setup
Work procedure, or lack of Flooring/ ground
Repetitive motion Lighting
Tool/ equipment condition Ventilation
Tool/ equipment availability
Other:
Personal protective
equipment availability
Personnel‐related: (Check all that possibly apply)
Tool/ equipment use or selection Work pacing
Level of support/ assistance
Other:
Awkward posture(s)
Personal protective equipment use
Following of procedure/ instruction
Level of attention to task
Possible Root Cause(S): (Factors contributing to the workplace condition(s) or action(s) identified above)
(Check all that possibly apply)
Awareness of job hazards
Level of training
Level of inspection/ maintenance
Level of communication
Level of resources available
Other:
Additional details on possible cause(s):
PART 5: PLANNED FOLLOW‐UP EFFORTS
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ FOR FURTHER CONSULTATION, CALL EHS AT 554‐5078 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Check all that possibly apply:
Conduct ergonomic evaluation (01) Post safety signage in area (06) Review as job performance issue (10)
Evaluate equipment/ facility condition (02)* Review inspection and/ or maintenance
Other (11):
Provide appropriate tool/ equipment (03) program (07)
Provide personal protective equipment (04) Review formal work procedure (08)
Provide initial/ refresher training (05) Assess newly identified hazard(s) (09)
* For facility‐related concerns contact Facilities at 554‐4742
Follow‐up Action:
For each follow‐up effort checked above, indicate its action code (# in parentheses) and describe the planned action. As actions are completed,
record completion date, and initial the original copy for local recordkeeping purposes.
Action Code
Description of Planned Action
Date Completed
Supervisor Initial
Can submit form before
completing
Can submit form before
completing
Supervisor Signature** Date
** Signing of this form does not constitute acceptance or assignment of individual fault
PART 6: IMMEDIATELY EMAIL TO spcollins@scu.edu or FAX THIS FORM TO EHS AT 554‐4734
Employee Last Name:
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Page 3 of 3
SCU Incident Form (11/2017)
EMPLOYEE INCIDENT
DESCRIPTION-
Additional
space to continue description(s) if
needed
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Completed 26 August 2020

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