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, 学生, 或者客人.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*: 转变: Department/Location*: II. Injured Person名称*: A number*(enter "NA" if not applicable): 状态* Full Time Employee Part Time Employee Contractor Temporary Employee 学生 客人 其他 地址: 年龄*: 电话*: Job Title*(enter "学生" if you are a 学生): Supervisor/Associated Faculty member*: Length of 就业 at IIT: Length of 就业 at Job: Nature of Injury* 瘀伤 Dislocation Strain/Sprain Scratch/Abrasion 内部 骨折 截肢 Foreign Body Laceration/Cut 烧伤和烫伤 Chemical Reaction其他 (Specify):Injured body part:备注:治疗Name and address of treating physician or facility急救:Emergency room:Medical office visit:Hospitalization:3. 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@302252.com)IV. Root Cause Analysis*Check All That 应用 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 其他 Inadequate Fall Protection Improper Loading/Placement Poor Workstation/Process Design/Layout Congested Work Area Hazardous Substance 没有个人防护用品 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 未知的其他V. 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@302252.com)*.How Bad Could the Accident Have Been?* Very 严重的 严重的 小 那么糟糕 很有可能What Is the Chance of the Accident Happening Again?* Very 可能 可能 可能的 不太可能VI. Preventative Actions*Describe actions that will be taken to prevent recurrence*:截止日期*:Responsible Party*:7. Investigation Team名称*: Position*: 日期*: 名称: 位置: 日期: 名称: 位置: 日期: 8. Person Completing this Form名称*: Email address*: 日期*: File UploadOnly PDFs, Microsoft Word documents, and .PNG和 .JPEGS images can be uploaded, no larger than 1MB.Security CheckSecurity Check*: Can't read the image? 点击这里 刷新!
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, 学生, 或者客人.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*: 转变: Department/Location*: II. Injured Person名称*: A number*(enter "NA" if not applicable): 状态* Full Time Employee Part Time Employee Contractor Temporary Employee 学生 客人 其他 地址: 年龄*: 电话*: Job Title*(enter "学生" if you are a 学生): Supervisor/Associated Faculty member*: Length of 就业 at IIT: Length of 就业 at Job: Nature of Injury* 瘀伤 Dislocation Strain/Sprain Scratch/Abrasion 内部 骨折 截肢 Foreign Body Laceration/Cut 烧伤和烫伤 Chemical Reaction其他 (Specify):Injured body part:备注:治疗Name and address of treating physician or facility急救:Emergency room:Medical office visit:Hospitalization:3. 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@302252.com)IV. Root Cause Analysis*Check All That 应用 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 其他 Inadequate Fall Protection Improper Loading/Placement Poor Workstation/Process Design/Layout Congested Work Area Hazardous Substance 没有个人防护用品 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 未知的其他V. 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@302252.com)*.How Bad Could the Accident Have Been?* Very 严重的 严重的 小 那么糟糕 很有可能What Is the Chance of the Accident Happening Again?* Very 可能 可能 可能的 不太可能VI. Preventative Actions*Describe actions that will be taken to prevent recurrence*:截止日期*:Responsible Party*:7. Investigation Team名称*: Position*: 日期*: 名称: 位置: 日期: 名称: 位置: 日期: 8. Person Completing this Form名称*: Email address*: 日期*: File UploadOnly PDFs, Microsoft Word documents, and .PNG和 .JPEGS images can be uploaded, no larger than 1MB.Security CheckSecurity Check*: Can't read the image? 点击这里 刷新!