Fillable Work Related Accident/Incident Report (Clarke College)

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Work Related Accident/Incident Report (Clarke College)

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Work Related
Accident/Incident Report
Individual Involved Type of Incident: Near Miss ___, Injury ___, Property Damage ___.
Print all information in black ink
Event Details
Medical Treatment
Result of Injury:
(Check all that apply)
First Aid Treatment
Medical Treatment
Job Restriction/Light Duty
Job Transfer
Other__________________
Future Medical Care:
Very Likely
Not Sure
Not Likely
Medical Evaluation / Treatment:
____ Tri State Occupational Health, 19
th
at Elm, 584-4600
____ Medical Associates, 1000 Langworthy, 584-3000
____Mercy Hospital ER, 589-9666
____Other ________________________________________
Employee Name: ____________________________________________
Last First
Department & Job Title:______________________________________
Supervisor:
______________________
Full Time:___ Part Time:___
Staff ____ Student Worker ___
Faculty ___ Other ________________
___________________
Date & Time Of Incident:
Date: ________________
Time: ________________
AM PM
If the report was not completed
within 24 hours, why?
___________________________
___________________________
___________________________
___________________________
Work activity at time of incident?
_______________________________
_______________________________
_______________________________
Is this the employees regular work
activity? Yes ____ No _____
Specific Location of Incident:
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Date & Time Reported:
Date: _____________________
Time: _____________________
AM PM
Reported To: _______________
Nature of injury:
Sprain/Strain
Laceration
Irritation
Repetitive Motion
Foreign Body
Fracture/Dislocation
Burn
Other __________________
Body Part Injured:
Witness(s) to the incident:
Name: _________________________
Address: _______________________
Phone #: _______________________
Name: _________________________
Address: ______________
_________
Phone #: _______________________
Photo Taken: YES __ NO __
By: ________________________
How did the incident/injury occur: (Include equipment, Vehicle, tools, chemicals, PPE used, weight and size of material, etc.)
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
_______________________________________
_____________________________________________________________________________________
______________________________
______________________________________________________________________________________________
____________________________________________________________________________________________________________________________
________________________________________________________________
____________________________________________________________
______________________________
______________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Employee Signature: _________________________________ Date: ______________________
__
(Involved employee to describe, in detail, what happened. Use additional sheet if needed)
Incident Investigation
INCIDENT FACTS: List all causes and contributing factors for each of the following categories listed below:
1. Job Activities – List the specific actions or activities of the employee that may have contributed to this incident and why:____________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
2. Employee Factors – Identify PPE (personal protective equipment) used, apparel worn, employee training, job knowledge/planning,
preoccupation or employee physical factors involved and why: ___________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
3. Work Practices – List any accepted and/or unapproved or unsafe work practices that were being performed and why: _______________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
4. Tools, Equipment, & Machinery – List all equipment that was involved including the condition and appropriateness of use and why:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
5. Work Environment – Identify the environmental factors including weather conditions, housekeeping, working surfaces, lighting, etc.
that may have contributed to the incident and why: ____________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
RECOMMENDED CORRECTIVE ACTIONS: List below, the specific corrective
action(s) that can be taken to eliminate each of the unsafe or inappropriate causes or
contributing factors listed above:
Person
Responsible for
Implementation:
(Name)
Date Action
to be
Completed
by:
Date Action
Completed:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
______________________________ __________ _____________________________ _____________
Investigating Supervisor Date Safety Committee Representative Date
______________________________ __________ _____________________________ _____________
Director Safety & Security Date V.P. Business & Finance Date
______________________________ __________ Submit to Director Safety & Security within 24 hours of incident.
Director Human Resources Date (Revised January 2009)
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Work Related AccidentIncident Report (Clarke College)

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Completed 22 July 2020

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