Incident Report And Investigation Form printable pdf download

Incident Report and Investigation Form

Incident Number: 201__-____

Rev. date: May 28, 2015

1. Injury/Illness: (to be completed by injured person)

Date: _________________ Faculty/Department/Contractor: ______________________________

Incident Type(s): [ ] Injury

[ ] Exposure

[ ] Illness

[ ] Property Damage

[ ] Fire

[ ] Spill

[ ] Biological Related *

[ ] Environmental

[ ] Near Miss

[ ] Biosecurity *

[ ] Other

Incident Date (dd/mm/yy): ___/___/___

Time of Incident

:__________

(24 hour clock)

Reported on: ___/___/___

Time Reported

:__________ Supervisor: ______________________

(24 hour clock)

Building/Area: _____________________

Specific Location: ______________________

[ ] Staff [ ] Faculty [ ] Student [ ] Grad Student

[ ] Contractor [ ] Public [ ] Lost Time: ________

Name: ___________________________________ ID Number: _____________ Years at UPEI: _____

Home Phone: ________________ Work Phone: _____________ Email:__________________________

Position: __________________________ Body part(s) affected: _______________________________

Describe Incident: ___________________________________________________________________

__________________________________________________________________________________

Was first aid given? [ ] Yes [ ] No By whom? __________________ AVC- Animal’s patient #_____

Was injured transported to medical aid? [ ] Yes

[ ] No

By whom? __________________________

Where to? _________________________________ Name of Doctor: __________________________

Injured during normal work? [ ] Yes

[ ] No

WCB completed and attached

[ ] yes

[ ] no

2. Witnesses:

Name: __________________________ Department: _______________________ Phone: _______________

Sections 3-5: completed by Supervisor:

3. Property/Equipment/Environmental Damage/Impact:

Describe Damage/Impact: __________________________________

____________________________

4. Analysis/

Causes: ___________________________________________

___

________________________________________________________________________________________

5. Recommended corrective action(s):

Immediate & Long term: ____________________________________________________________________

________________________________________________________________________________________

Person(s) responsible for action(s)/Department: ______________________________________________

Actions taken

___________________________________________________________________________

6. Signatures:

Form must be signed by employee and supervisor before returning to Human Resources

Injured Person: _____________________________________ Date: ____________________

Supervisor/Investigator: _______________________________ Date: ____________________

Director/Chair: _______________________________ Date: ____________________

HR0155 v2(20111013)

*If Biological Related please contact Biosafety Officer

Incident Report And Investigation Form

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