RMU Incident Investigation and Report Form Instructions: Fill in form by clicking on fields to enter data. Save file and print for proper distribution. SECTION I. INCIDENT INFORMATION Date of Incident Time of Incident Location of Incident: (Be specific to building, room, area, or location on premises ex. ISC, Golf (m/d/y) AM PM Dome, Practice Range, North Stair to mezzanine)
Incident Investigation / Report completed by (Employee or Department Supervisor name): Witness(es) to Incident:
Name/phone number Name/phone number
SECTION II. INJURED PERSON DETAILS Name of Injured Person:
Male Female
Age:
Home Ph: Cell Ph:
Address: Person Injured Is: RMU Employee
Department: Full-Time
RMU Student
Position: Part-Time
Was Person Involved In:
Student Emp. League
Staff Start Time:
Other Describe:
Sporting Event
Other
Explain event: Visitor / Guest
Release / Waiver Signed?
Yes (forward copy with report)
Equipment Involved in Incident?
Owned by RMU
No
Owned by other
Describe equipment: SECTION III. INJURY DESCRIPTION
Nature of Injury:
Bruising
Dislocation
Strain/Sprain
Scratch/Abrasion
Internal
Fracture
Amputation
Foreign Body
Laceration/Cut
Burn/Scald
Chemical Reaction
Treatment:
Needle Stick Other Explain here:
List Body Part(s) Injured:
Emergency/Ambulance (List where taken)
None First Aid
Other Explain:
SECTION IV. DAMAGED PROPERTY Name of Property, Equipment or Material Damaged: Description of Damage:
Cause of Incident / Damage: SECTION V: DESCRIPTION OF INCIDENT Describe in detail what happened (attach photographs or diagrams if necessary):
RMU Incident Investigation Form
Page 1 of 2
Rev. 9/11
RMU Incident Investigation and Report Form SECTION VI: ROOT CAUSE ANALYSIS (Check All That Apply)
Unsafe Acts
Unsafe Conditions
Management Deficiencies
Improper work technique
Poor workstation design or layout
Lack of written procedures or policies
Safety rule violation
Congested work area
Safety rules not enforced
Improper PPE or PPE not used
Hazardous substances
Hazards not identified
Operating without authority
Fire or explosion hazard
Personal Prot. Equip. unavailable
Failure to warn or secure
Inadequate ventilation
Insufficient worker training
Operating at improper speeds
Improper material storage
Insufficient supervisor training
By-passing safety devices
Improper tool or equipment
Improper maintenance
Guards not used
Insufficient knowledge of job
Inadequate supervision
Improper loading or placement
Slippery conditions
Inadequate job planning
Improper lifting
Poor housekeeping
Inadequate hiring practices
Servicing machinery in motion
Excessive noise
Inadequate workplace inspection
Horseplay
Inadequate guarding of hazards
Inadequate equipment
Drug or alcohol use
Defective tools/equipment
Unsafe design or construction
Unnecessary haste
Insufficient lighting
Unrealistic scheduling
Unsafe act of others Other: Explain
Inadequate fall protection Other: Explain
Poor process design Other: Explain
Incident Analysis – describe what action, condition, and / or circumstances caused the incident:
Summarize other conditions related to the incident -even contributing factors that may have reduced the severity. (ex. What type of personal protective equipment (PPE) was being worn-gloves, safety glasses, goggles, mask, etc.?):
SECTION VII: PREVENTIVE OR CORRECTIVE ACTIONS Describe the actions that will be taken to prevent recurrence: Explain
Responsible person:
Date to be completed by:
Explain
Responsible person:
Date to be completed by:
SECTION VIII: SIGNATURES Employee / Person Involved:
Date: Sign Here:
Print name:
Department Supervisor / Manager:
Date: Sign Here:
Print name:
SECTION IX: DISTRIBUTION Per policy, send completed report to: (include all attachments)
Unsafe Acts. Unsafe Conditions. Management Deficiencies. Improper work technique. Poor workstation design or layout. Lack of written procedures or policies. Safety rule violation. Congested work area. Safety rules not enforced. Improper PPE or PPE not used. Hazardous substances. Hazards not identified. Operating ...
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