ࡱ> g ~bjbjVV 4r<r<y3N N 8,U(!!!!"*+,UUUUUUU$XZ(UZ-))@Z-Z-(U!!,U000Z-p!!U0Z-U0066NP!yOy-OTU0U2OO[d.O[8PO[P8Z-Z-0Z-Z-Z-Z-Z-(U(Ur0dZ-Z-Z-UZ-Z-Z-Z-O[Z-Z-Z-Z-Z-Z-Z-Z-Z-N n: CSU East Bay Supervisor s Incident Investigation & Follow-upEMPLOYEE DATAEmployee Name:  FORMTEXT      Sex:  FORMCHECKBOX  Female  FORMCHECKBOX  MaleDate of Hire:  FORMTEXT      Department/Location:  FORMTEXT      Employee ( FORMCHECKBOX ) Volunteer ( FORMCHECKBOX ) Student-Employee ( FORMCHECKBOX ) Non-Employee ( FORMCHECKBOX )Supervisor s Name:  FORMTEXT      Supervisor s Work Phone:  FORMTEXT       Employee s accident report(s) attached:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Police report attached:  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  NA Supervisors report attached:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Witness statements attached:  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  NAWere other employees injured?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  NA Are report(s) attached?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  NAIf so who? Incident type: Injury/Illness  FORMCHECKBOX  Property Damage  FORMCHECKBOX  Injury and property damage  FORMCHECKBOX  Near Miss  FORMCHECKBOX  Hazmat Spill  FORMCHECKBOX  3rd Party involved  FORMCHECKBOX  _____________________ Vehicle Damage (ORIM Std 270 Form Completed)  FORMCHECKBOX  ________________ Other  FORMCHECKBOX  ____________________________________________________________________________________________Detailed description of Incident (if needed attach additional information):  FORMTEXT       Comments/Diagrams/Other (if needed attach additional information):  FORMTEXT        DIRECT CAUSEINDIRECT CAUSESBASIC CAUSE FORMCHECKBOX  Struck by or against object (indicate) ______________  FORMCHECKBOX  Caught in/under/ between  FORMCHECKBOX  Fall / Slip / Trip  FORMCHECKBOX  Material handling or lifting  FORMCHECKBOX  Repetitive motion  FORMCHECKBOX  Chemical exposure  FORMCHECKBOX  Body fluid exposure: __Needle stick __Sharps  FORMCHECKBOX  Animal bite  FORMCHECKBOX  Other, Explain Dust/grime in eye________________________________________________________ Equipment  FORMCHECKBOX  Equipment failure  FORMCHECKBOX  Equipment unavailable  FORMCHECKBOX  Improper equipment or material used for job Personal protective equipment  FORMCHECKBOX  Not worn  FORMCHECKBOX  Not readily available  FORMCHECKBOX  Not adequate for the task  FORMCHECKBOX  Personal protective equipment failure Training/Experience  FORMCHECKBOX  Lack of training  FORMCHECKBOX  Safety training provided, not followed  FORMCHECKBOX  New task for employee or lack of experience Work Area  FORMCHECKBOX  Work area set up improperly  FORMCHECKBOX  Inadequate lighting or noise issues  FORMCHECKBOX  Housekeeping issues  FORMCHECKBOX  Environmental factors (rain, wind, temp. etc) FORMCHECKBOX  Ventilation issues  FORMCHECKBOX  Ergonomic factors Employee  FORMCHECKBOX  Physically not able to do work  FORMCHECKBOX  Employee fatigue  FORMCHECKBOX  Unbalanced or poor position or motion  FORMCHECKBOX  Incorrect procedures used for task  FORMCHECKBOX  Other unsafe practice Assistance  FORMCHECKBOX  Difficult to perform task without help  FORMCHECKBOX  Safety features or devices not readily available  FORMCHECKBOX  Assistive devices not used  FORMCHECKBOX  Lack of policy/procedure  FORMCHECKBOX  Animal (explain below)  FORMCHECKBOX  Other (explain) ___________________________________________________________________________________________________________________ Use additional pages as needed.Management Safety Policies & Decisions Inadequate personnel practices regarding:  FORMCHECKBOX  Training  FORMCHECKBOX  Job observation  FORMCHECKBOX  Communication  FORMCHECKBOX  Improper employee assignment  FORMCHECKBOX  Improper/no assignment of responsibility/ accountability  FORMCHECKBOX  Other Procedures do not provide for:  FORMCHECKBOX  Adequate housekeeping  FORMCHECKBOX  Preventive maintenance  FORMCHECKBOX  Communication of hazards and means of control  FORMCHECKBOX  Documented safe work practices or procedures  FORMCHECKBOX  Follow up and/or tracking of hazard correction  FORMCHECKBOX  Safety inspections  FORMCHECKBOX  Other Safety is not considered in the purchase, installation or use of:  FORMCHECKBOX  Equipment, machinery tools  FORMCHECKBOX  Supplies or materials  FORMCHECKBOX  Outside services  FORMCHECKBOX  Other Personnel Factors Experience factors:  FORMCHECKBOX  Unsafe practices  FORMCHECKBOX  Inadequate skills  FORMCHECKBOX  Insufficient knowledge  FORMCHECKBOX  History of accidents  FORMCHECKBOX  OtherBehavior factors:  FORMCHECKBOX  Lack of hazard awareness  FORMCHECKBOX  Inattention to tasks  FORMCHECKBOX  Inappropriate risk taking  FORMCHECKBOX  Repeat accident  FORMCHECKBOX  Other Physical factors:  FORMCHECKBOX  Lack of required strength  FORMCHECKBOX  Lack of required stamina  FORMCHECKBOX  Other Environmental Factors Unsafe operating procedures:  FORMCHECKBOX  Routine  FORMCHECKBOX  Emergency  FORMCHECKBOX  Other Unsafe projections/surfaces:  FORMCHECKBOX  Equipment  FORMCHECKBOX  Supplies/materials  FORMCHECKBOX  Structure/furnishings  FORMCHECKBOX  Other Unsafe location factors:  FORMCHECKBOX  Terrain (uneven, unstable)  FORMCHECKBOX  Surroundings (equipment, people)  FORMCHECKBOX  Weather conditions  FORMCHECKBOX  Access (blocked exits)  FORMCHECKBOX  Other Unsafe facility design:  FORMCHECKBOX  Access (blocked exits)  FORMCHECKBOX  Utility layout (electrical outlets, mechanical & hydraulic systems)  FORMCHECKBOX  Lighting, HVAC, noise  FORMCHECKBOX  Material handling  FORMCHECKBOX  Other Action(s) to be takenResponsible PersonTarget DateCompletion Date FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Employee SignatureDate:  FORMTEXT      Supervisor s or Manager s Signature:Date:  FORMTEXT      EHS Review:Date:  FORMTEXT      EHS use onlyTreatment: :  FORMCHECKBOX  No treatment  FORMCHECKBOX  First Aid  FORMCHECKBOX  Medical treatment, treated at  FORMTEXT        FORMCHECKBOX  OSHA Recordable  FORMCHECKBOX  OSHA ReportableRestriction:  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  NA Lost work day:  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  NAAttach additional information Instructions for Completing the Accident Investigation Report Employee Data Employee Name: Record the name of the employee involved. Sex: M=male; F=female Date Hired: This field will have value for analyzing the incidence of occupational injury and illness among newly hired workers and those with longer tenure. For the relatively infrequent situation where employees are hired, terminated, and then rehired, the employer can, at his or her discretion, enter the date the employee was originally hired, or the date of rehire. Department / Location: The regular department is the "home base" of the employee. It may not necessarily be the department in which the incident occurred. For example, a maintenance person who was injured in the Chemistry department would record Maintenance Department as the regular department. Leave this field blank if the incident was a near miss, which did not involve a person. Check if the incident involved an Employee, Volunteer, Student-Employee, Non-Employee. Job Title: Record the job title to which the employee is regularly assigned. Number of hours worked during the day and week. Usual work days: Week days the employee usually works, included any normal weekend work days. Usual work times: Self-explanatory Employees Work Phone: University phone number where employee can be reached. Employees Home Phone No: Include this phone number if the employee generally works from home. Supervisor Name: Record the name of the employees supervisor. Supervisor Work Phone: Record the phone number of the employees supervisor. Incident Information Date/Time employee began work - Record day, month and year the employee started work on the day of injury. If not known because it is a latent health issue, write unavailable. Date of Injury / Illness: Record day, month and year of incident. For latent health issues, record the date when the illness was diagnosed or record the date of the hearing test when the hearing loss was detected. Location where injury or illness occurred: List the exact location of the incident. For example, Chemical Sciences Room 305. Date the Supervisor knowledge or notice of the injury/illness: Self explanatory Nature of Injury. Please classify nature of injury. Burn, bite, chemical splash, fall, etc. Body Part(s) affected: Self explanatory. Were other employees injured: If yes, attached their completed Employee Injury and Illness Form Check the Incident type(s): Injury or illness / Property Damage / Injury and property damage / Near Miss / Hazmat Spill / 3rd Party involved / Vehicle Damage / Other. If there is state vehicle damage the ORIM-DGS Std 270 Form must be completed and submitted. Employees report(s) attached. Record employees statement(s) as to what occurred. Witness and Witness Statement. Record witness name and witness statement as to what occurred (if applicable). Detailed description of Incident: Supervisors Findings: Record any findings supervisor may have regarding the incident. Comments/Diagrams/Other: Self-explanatory Direct / Indirect / Basic Causes In spite of their complexity, most incidents are preventable by eliminating one or more causes. Investigations determine not only what happened, but also how and why. The information gained from these investigations can prevent recurrence of similar or perhaps more serious incidents. Investigative team efforts must focus on all events, as well as the sequence of events, that led to an incident. Direct Cause Unplanned release of energy or hazardous material. Example: The knife that cut (laceration) the palm of the hand. Please choose the most appropriate choice. Indirect Cause Symptoms Unsafe Acts and/or Unsafe Conditions. Example: Tripping over unrolled hose left on floor causing contusion to knee. Please choose the most appropriate choice(s). There may be more than one choice. Basic Causes (Poor) Management Policies or Decisions, or to Personal or Environmental Factors. Example: Lack of instruction in proper cutting techniques. Lack of supervision to reinforce safe work practices. Personal decision by individual to take a short-cut to save time. Please choose the most appropriate choice(s). There may be more than one choice. 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