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Incident Investigation Form: Physical Plant Safety Office Auxiliary & Business Services Safety Office

1. The document is an incident investigation form used to report employee injuries, near hits, or property damage. 2. It requires information about the employee, accident details, contributing factors, corrective actions, and supervisor signatures. 3. Relevant details include the date and location of the incident, the employee's actions, any injuries sustained or potential injuries avoided, contributing causes, recommended solutions, and follow up actions to prevent future occurrences.

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51 views2 pages

Incident Investigation Form: Physical Plant Safety Office Auxiliary & Business Services Safety Office

1. The document is an incident investigation form used to report employee injuries, near hits, or property damage. 2. It requires information about the employee, accident details, contributing factors, corrective actions, and supervisor signatures. 3. Relevant details include the date and location of the incident, the employee's actions, any injuries sustained or potential injuries avoided, contributing causes, recommended solutions, and follow up actions to prevent future occurrences.

Uploaded by

SADHED
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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.

Employee Injury Near Hit Incident Property Damage

Submit completed form to one of the following locations:

Physical Plant Safety Office Auxiliary & Business Services Safety Office
103 Physical Plant Building 127 Johnston Commons
University Park, PA 16802 University Park, PA 16802

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: _______________________________________________
Supervisor Name: Signature:

Accident Data/Contributing Factors


Detailed narrative of how incident occurred:

Description of Pictures Taken:

What was employee doing just prior to accident (job task, include any tools or machinery used):

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? Yes No
Was there any damage to property or equipment? Yes No
Explain:
Name(s) of witness(es): Phone#
Name(s) of witness(es): Phone#

Causes
PLEASE CHECK ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS

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:
____________________________

Corrective Actions
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:

What action was or should be taken to prevent recurrence?

Corrective actions completed? Yes No If no, explain:

Investigated by: Date:

Reviewed by: Date:

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