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Incident Report and Investigation Form

An incident report form documents an incident involving a staff member at a university. The form collects details about the incident such as the staff member's name and contact information, date and time of incident, location, description of the incident and any resulting injuries or property damage. Witness information is also recorded. The incident investigation section analyzes the root cause and lists control measures to prevent future occurrences. The completed form should be sent to the university's Environmental Health and Safety team and the staff member's Divisional EHS Coordinator.

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Christine Kho
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194 views

Incident Report and Investigation Form

An incident report form documents an incident involving a staff member at a university. The form collects details about the incident such as the staff member's name and contact information, date and time of incident, location, description of the incident and any resulting injuries or property damage. Witness information is also recorded. The incident investigation section analyzes the root cause and lists control measures to prevent future occurrences. The completed form should be sent to the university's Environmental Health and Safety team and the staff member's Divisional EHS Coordinator.

Uploaded by

Christine Kho
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Incident Report and Investigation Form

Incident Report Section


Surname: First name: Telephone number:
Inciden

person

Gender: Division/Room No.: Length of employment/study:


t

Date: Time: Location of incident (Building & Room No.)

Was the person authorized there? Incident classification


Injury □ Ill health Near miss □
Description
of incident

Describe work/activity being performed and the incident:

Describe injury /property damaged:

None First aid Hospital More than 1-3 days More than 3 Major injury
required treatment 24 hours in absence days
treatment
Medical

hospital absence

Name and address of witness(es):


information
Other

Name of person making report: Telephone:

Division/Room No.: Date:


Incident investigation section
Falls on level/stairs Falls from height
Struck or trapped by object striking against fixed or stationary object
Causative agents

Fire/explosion Electricity
Sharps Handling/lifting
Hot/cold contact Defective premises/equipment
Exposure to toxic substance or pathogen Unintentional chemical spillage
Work related vehicle/traffic incident Live animal
Occupational illness Other (Specify)
Describe the incident cause
cause
Root

Investigated by
No. Control measures Completion date Due date Responsible person
measures
Control

Investigated by

Remark: Please send the report to Campus EHS team at [email protected] and your Divisional EHS Coordinator, after completing
the incident report section.

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