Incident Investigation Report
Note:
This report should be completed within 24 hours (or as SOON thereafter
as possible) of any incident, even if minor (whether accident, injury, property
damage, fire, chemical or hazardous substance exposure, or “near miss” situation)
and sent to the Director of Environmental Health and Safety, Heating/Cooling
Plant. If this is a faculty/staff/student worker on the job incident, you ALSO
need to complete the Employer’s Accident Report (http://counsel.wlu.edu/policy/Employer'sAccidentReport.pdf) within 24 hours and send it to the Director of
Environmental Health and Safety.
If this is a serious incident involving
faculty or staff, notify Paul Burns, Director of Environmental Health and
Safety, immediately, 24 hours a day at x8175, (C) 460-6209 or (H)
540-962-1703. For other serious
incidents, notify the University Department of Public Safety immediately,
24 hours a day, at x8999 (or Director Mike Young at x8427, (C) 460-3726, (Pager) 464-2505) . In such cases, the Director of Environmental
Health and Safety or the Director of Public Safety or designee may conduct or
take part in the investigation.
SECTION I - - Individual sustaining
accident/injury/exposure
Name
Affiliation: O Faculty/Staff O Student O Student Employee
O Guest/Vendor/Contractor O Alumnus/Alumna
Position, department, and supervisor (if employed at W&L) _____________________________
Length of employment and period of time in present position (if employed at W&L)
Home Phone and Cell Phone
Home Address
Email Address
SECTION II - - Details of Incident
Date of Incident____________________ Time of Incident_______________Oa.m. Op.m.
(If work-related) Date
Supervisor Notified
(If not work-related)
Receiving Notice
Category:
Injury/Illness
Property Damage
Fire
Exposure
______ Near Miss
______ Other (explain)
Exact location where incident occurred
What was the person doing when the incident occurred?
Describe in detail what happened (do not simply state, for example, that a person fell while walking
downstairs - - explain in detail what took place and what the person(s)
involved did/did not do, etc. OR, for example, if an oven fire developed in a
kitchen, do not simply state that
fact, but explain in detail what took place, and what the person(s) involved
did/did not do). Do not place blame for
the incident, but instead provide facts to explain how the incident happened.
Use additional pages if necessary.
Identify any witnesses to the incident
Identify any other individuals who have, or might have,
knowledge of any circumstances surrounding the incident
Are there documents relevant to the investigation? If so, provide a copy or indicate source so that they may be obtained for review (such as, police accident report, driver’s license and insurance information for vehicular accident, equipment operating manual).
Describe the physical/environmental/mechanical
conditions at the time of the incident (for example, if it happened out of
doors, what was weather and what were physical surroundings; or, if it happened
indoors and machinery/equipment/furniture was involved, where was it located, was
the equipment in good condition and properly operating, etc.)
Were the physical/environmental/mechanical conditions a factor in the incident?
Yes ___No___. If so, explain how/why.
(For work-related incidents)
Was safety equipment required at the time of the incident (glasses, goggles, gloves, shoes, apron, hard hat, harness, ear plugs, etc.) and, if so, what equipment? If so, was such equipment being used at the time of the incident? ___Yes No. If required and not being used, might such equipment have prevented the incident or minimized any injury? Explain.
Had the individual(s) involved been trained in the use of any required safety equipment, and how to do the task at hand safely? Yes No
Was the task at hand part of the individual’s normal
job? ____Yes ____No. If no, explain.
Does the incident involve a possible violation of a University policy, department or office safety/health rule or supervisor directive? ___ Yes ___ No. If yes, explain.
(For all incidents)
What actions have been taken or could be taken to prevent or minimize a recurrence of this type of incident?
SECTION THREE - - Details of injury/medical treatment
and property damage to NON-UNIVERSITY property
Describe type of injury and part of body affected - - BE SPECIFIC! (i.e. three-inch long deep cut on tip of left index finger, pain in lower left back, twisted right ankle, foreign object in left eye, superficial burns on left elbow and front of left upper arm, etc.)
When did individual first notice injury or feel/sense any symptom, pain, or trauma to that part of the body? (for example, employee felt a pop in right shoulder when reaching for something, though no pain until the following morning OR employee was moving boxes yesterday and didn’t notice anything at the time, but now her back hurts)
Describe any medical treatment administered (none, first aid on site, seen at the W&L student health center, taken to the emergency room, treated by personal physician, etc.)
(For work-related injuries)
Did the individual miss any work? ___ Yes ___ No. If so, state period of work time missed and
date of return/expected return
(For all incidents with property damage to non-University property or other loss) Explain nature and specifics of property damage or other loss sustained by the individual(s) involved.
SECTION FOUR - - Details of property damage to
UNIVERSITY property
Explain nature and specifics of damage to University
property.
Signature of investigating Supervisor Date
Signature of reviewing Sup./Dept. Head Date
Signature of Director of Environmental Health and Safety Date
Comments and additional corrective/preventive action
required:
Director of Environmental Health and Safety (Official
record keeper) will provide a copy of this report, if he deems necessary, to
one or more of the following university officials, depending on the circumstances
of the incident.
Vice-President
for Administration
Director
of Public Safety
Director
of Facilities Management
Office
of the Treasurer
Office
of General Counsel
Director
of Human Resources (only for work-related incidents)