This form must be completed and returned to Human Resources within 2 working days of the work or study related injury or illness of an employee, student, or guest.Note to person completing this form: An accident investigation is not designed to find fault or blame. It is an analysis to determine causes that can be controlled or eliminated.Once submitted, this form will be routed electronically to (1) the University Laboratory Safety Coordinator or Director of Environmental Health and Safety, as appropriate, (2) the Office of Human Resources, and (3) the Office of General Counsel. The University Laboratory Safety Coordinator or Director of Environmental Health and Safety will route it to the head of the appropriate department.I. Incident InformationDate injury occurred*: Time of injury*: Shift: Department/Location*: II. Injured PersonName*: A number*(enter "NA" if not applicable): Status* Full Time Employee Part Time Employee Contractor Temporary Employee Student Guest Other Address: Age*: Phone*: Job Title*(enter "student" if you are a student): Supervisor/Associated Faculty member*: Length of Employment at IIT: Length of Employment at Job: Nature of Injury* Bruising Dislocation Strain/Sprain Scratch/Abrasion Internal Fracture Amputation Foreign Body Laceration/Cut Burn/Scald Chemical ReactionOther (Specify):Injured body part:Remarks:TreatmentName and address of treating physician or facilityFirst aid:Emergency room:Medical office visit:Hospitalization:III. Damaged PropertyProperty, equipment or material damaged:Description of damage:Object or substance causing damage:Describe what happened:(Please email photographs or diagrams if necessary to hr@iit.edu)IV. Root Cause Analysis*Check All That Apply Based on Observable/Known Facts Improper Work Technique Safety Rule Violation Improper PPE or PPE Not Used Inadequate Ventilation/Lighting Improper Material Storage By-Passed Safety Device/Guard Slippery Conditions Improper Lifting Horseplay/Unsafe Act of Other Inadequate Fall Protection Improper Loading/Placement Poor Workstation/Process Design/Layout Congested Work Area Hazardous Substance No PPE Insufficient Worker Training Improper Maintenance/Inspection Improper/Inadequate Tools/Equipment Inadequate Job Planning/Scheduling Poor Housekeeping Drug/Alcohol Use Inadequate Guarding of Hazard No Written Procedure/Policy Safety Rule Not Enforced Operating Without Authority Failure to Warn/Secure Inadequate Operating at Improper Speeds Insufficient Supervisor Training Insufficient Knowledge of Job Inadequate Supervision Excessive Noise Servicing Machine In Motion Unnecessary Haste UnknownOtherV. INCIDENT ANALYSISUsing the Root Cause Analysis list above, explain the cause(s) of the incident in as much detail as possible, focusing on known facts (Please email an extended explanation if needed to hr@iit.edu)*.How Bad Could the Accident Have Been?* Very Serious Serious Minor As Bad As LikelyWhat Is the Chance of the Accident Happening Again?* Very Likely Likely Possible UnlikelyVI. Preventative Actions*Describe actions that will be taken to prevent recurrence*:Deadline*:Responsible Party*:VII. Investigation TeamName*: Position*: Date*: Name: Position: Date: Name: Position: Date: VIII. Person Completing this FormName*: Email address*: Date*: File UploadOnly PDFs, Microsoft Word documents, and .PNG and .JPEGS images can be uploaded, no larger than 1MB.Security CheckSecurity Check*: Can't read the image? Click here to refresh!
This form must be completed and returned to Human Resources within 2 working days of the work or study related injury or illness of an employee, student, or guest.Note to person completing this form: An accident investigation is not designed to find fault or blame. It is an analysis to determine causes that can be controlled or eliminated.Once submitted, this form will be routed electronically to (1) the University Laboratory Safety Coordinator or Director of Environmental Health and Safety, as appropriate, (2) the Office of Human Resources, and (3) the Office of General Counsel. The University Laboratory Safety Coordinator or Director of Environmental Health and Safety will route it to the head of the appropriate department.I. Incident InformationDate injury occurred*: Time of injury*: Shift: Department/Location*: II. Injured PersonName*: A number*(enter "NA" if not applicable): Status* Full Time Employee Part Time Employee Contractor Temporary Employee Student Guest Other Address: Age*: Phone*: Job Title*(enter "student" if you are a student): Supervisor/Associated Faculty member*: Length of Employment at IIT: Length of Employment at Job: Nature of Injury* Bruising Dislocation Strain/Sprain Scratch/Abrasion Internal Fracture Amputation Foreign Body Laceration/Cut Burn/Scald Chemical ReactionOther (Specify):Injured body part:Remarks:TreatmentName and address of treating physician or facilityFirst aid:Emergency room:Medical office visit:Hospitalization:III. Damaged PropertyProperty, equipment or material damaged:Description of damage:Object or substance causing damage:Describe what happened:(Please email photographs or diagrams if necessary to hr@iit.edu)IV. Root Cause Analysis*Check All That Apply Based on Observable/Known Facts Improper Work Technique Safety Rule Violation Improper PPE or PPE Not Used Inadequate Ventilation/Lighting Improper Material Storage By-Passed Safety Device/Guard Slippery Conditions Improper Lifting Horseplay/Unsafe Act of Other Inadequate Fall Protection Improper Loading/Placement Poor Workstation/Process Design/Layout Congested Work Area Hazardous Substance No PPE Insufficient Worker Training Improper Maintenance/Inspection Improper/Inadequate Tools/Equipment Inadequate Job Planning/Scheduling Poor Housekeeping Drug/Alcohol Use Inadequate Guarding of Hazard No Written Procedure/Policy Safety Rule Not Enforced Operating Without Authority Failure to Warn/Secure Inadequate Operating at Improper Speeds Insufficient Supervisor Training Insufficient Knowledge of Job Inadequate Supervision Excessive Noise Servicing Machine In Motion Unnecessary Haste UnknownOtherV. INCIDENT ANALYSISUsing the Root Cause Analysis list above, explain the cause(s) of the incident in as much detail as possible, focusing on known facts (Please email an extended explanation if needed to hr@iit.edu)*.How Bad Could the Accident Have Been?* Very Serious Serious Minor As Bad As LikelyWhat Is the Chance of the Accident Happening Again?* Very Likely Likely Possible UnlikelyVI. Preventative Actions*Describe actions that will be taken to prevent recurrence*:Deadline*:Responsible Party*:VII. Investigation TeamName*: Position*: Date*: Name: Position: Date: Name: Position: Date: VIII. Person Completing this FormName*: Email address*: Date*: File UploadOnly PDFs, Microsoft Word documents, and .PNG and .JPEGS images can be uploaded, no larger than 1MB.Security CheckSecurity Check*: Can't read the image? Click here to refresh!
