I. OVERVIEW:
An employee injured on the job is required to report the injury to his/her supervisor as soon as possible after the incident/accident. The supervisor is responsible first, to assure that any injured employee is given immediate and proper medical care (as required) and that no one else can be injured and, second, to immediately (within 8 hours) contact the Environmental Safety & Health office (EH&S – X 2401) to report the accident. Environmental Safety & Health staff is available to assist the supervisor with the accident investigation.
The purpose of accident investigation is to develop information on the actual and contributing causes of accidents in order to prevent recurrence. No matter how conscientious the safety effort at the University, accidents are sometimes going to happen due to human or system error. Our goal is to find and remove accident causes and to make the University a safer place to work. Accident investigations help us meet that goal.
The following is a brief overview of the investigation and report form (Form 620) that is required for every employee accident. All blanks should be filled in.
II. GENERAL INFORMATION:
This section identifies the injured employee, the department and employee status.
III. ACCIDENT DATA:
This section describes the accident with specifics on what the injured employee was doing and which body parts (right hand, left lower leg, back of head) were affected. The specific time and place (building, room, area) of the accident is important in the investigation.
The type of injury can be described by such terms as: foreign body in eye, cut, puncture, bruise, sprain, strain, fracture, burn, dermatitis, etc.
IV. INVESTIGATION:
The investigation section is completed in narrative format and consists of four parts: description of accident, cause of accident, corrective action and industrial injury verification.
V. DESCRIPTION OF ACCIDENT:
- What was the employee doing at the time of the incident?
- What sequence of events led to the incident
- What were the working conditions and tools being used?
- Any witnesses or contributors to the incident?
- How did the accident happen?
Some types include:
Struck against | Tripped | Absorbed |
Struck by an object | Overexertion | Ingested |
Caught in or between | Inhaled | Contact with electric current |
Slipped |
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VI. CAUSE OF ACCIDENT:
• Causes can include unsafe acts or equipment as well as poor or improper training. Other possible causes may include:
Improper instruction | Improper protective equipment | Improper maintenance |
Failure to train | Poor housekeeping | Improper safety device |
Lack of skill | Unsafe arrangement | Improper tool |
Operation without authority | Hazardous condition | Chemical spill |
Horseplay | Unsafe process or procedure | Lack of time |
Physical impairment | Unsafe lifting or carrying | Work overload |
Failure to warn or secure | Poor ventilation or lighting | Failure to inspect |
Failure to lockout | Improper guarding | Failure to enforce |
No inspection made |
| Unsafe position or speed |
VII. Corrective Action Taken or Recommended:
This section describes the corrective action that the supervisor has taken or will take to prevent similar accident from occurring. This may require action from other departments such as PPM for repairs or EH&S for training.
- Industrial Injury?
This is where the supervisor verifies that the injury occurred while the employee was on the job and covered by Workers’ Compensation. If the supervisor believes that the injury did not happen during the course of employment, an explanation is necessary.
VII. TREATMENT DATA:
This section details the treatment provided and who provided it. Note if the employee is off work because of the accidental injury and how long the employee will be off. Is modified duty available for the injured employee to return to work?
The supervisor must sign and date the report.
VIII. MISCELLANEOUS:
- Examine the accident site and preserve the scene if necessary.
- Take photos or make a diagram if it helps explain the situation.
- Remove/repair unsafe conditions.
- Interview witnesses as necessary.
- Be sure the report is legible.
- Use additional pages as required.
CALL Environmental Safety & Health (818) 677-2401
- For serious injuries or requiring overnight hospitalization.
- For any injured employee transported off campus for medical care.
- For assistance with the investigation.
- When in doubt.
If you have any questions regarding the completion of this report, please call Environmental Safety & Health on extension 2401.
IX. Revision Record
| Revision | Changes | Date |
| 1.1 | Review program and move to WebOne | May 2014 |
| 1.2 | Minor revisions and update broken link | Nov. 2018 |