LAKESIDE FIRE PROTECTION DISTRICT

Transcription

1 LAKESIDE FIRE PROTECTION DISTRICT INJURY & ILLNESS PREVENTION PROGRAM May 2014 (Updated February 2016)

2 Table of Contents Introduction 3 Purpose. 3 Safety Statement.. 3 Responsibilities. 4 District. 4 Safety Officer. 4 Division Chief/ Department Heads Responsibility. 4 Captain/ Supervisor Responsibility.. 5 Employees Responsibility.. 5 Compliance... 6 Communication Safety Meetings. 7 Safety Committee.. 7 Tailboard Meetings... 8 Workplace Hazards.. 8 Postings.. 9 Hazard Assessment.. 9 Accident/Injury/ Exposure Investigation and Reporting.. 10 OSHA 300 Log of Occupational Injuries and Illness Hazard Correction Training and Instruction.. 12 Record Keeping Other Programs General Safe Work Practices Forms Acknowledgement of District Safety Policy

3 INTRODUCTION Purpose The purpose of the Lakeside Fire Protection District (LFPD) Injury and Illness Prevention Program (IIPP) is to further the goals of the Lakeside Fire Protection District (LFPD). The goal of the LFPD is to minimize accidental injury or loss to employees, public, and property as well as to comply with the provisions of Title 8 of the California Code of Regulations (CCR), Section 3203, and the California Labor Code. This IIPP establishes employee safety and health policy and procedure for the Lakeside Fire Protection District and its operations, regardless of whether the operation is performed by a District employee or subcontractor. Where other documents are referenced within this IIPP, they shall be treated as though they were a part of this document. To comply with the California Occupational Safety and Health Act of 1973, also known as Cal OSHA, every employer must have a written Injury and Illness Prevention Plan (IIPP). The Lakeside Fire Protection District (LFPD) has developed our own IIPP. While no plan can guarantee an accident free work place, following the safety procedures set forth in this manual will reduce the risk of injury or illness to you and your co-workers. To the greatest degree possible, management will provide all mechanical and physical protection required for personal safety and health. Employees must also take responsibility for working safely. Policy The Lakeside Fire Protection District (LFPD) administers its activities to achieve and maintain a safe and healthful work environment, protecting employees and the public from unnecessary risks resulting from their operations. SAFETY POLICY To protect the safety and health of Lakeside Fire Protection District Employees, management shall: Place employee safety and health as the primary consideration in establishing work practices and procedures and in the selection of equipment. Give safety precedence over expediency and short cuts. Make every effort to control the possibility of accident occurrence to employees and members. Fully comply with, and enforce, all safety standards, regulations and District safety and health policies. 3

4 RESPONSIBILITY District Responsibility The Lakeside Fire Protection District (LFPD) and the Fire Chief accept the overall responsibility and accountability for providing a safe and healthful workplace for its employees. The Fire Chief delegates the day-to-day responsibility and authority for carrying out employee safety and health policy to specific District personnel. Safety Officer The Lakeside Fire Protection District (LFPD) has appointed a Safety Officer to assist department heads, managers, and supervisors in carrying out their responsibilities. The Safety Officer will: Ensure that every department has met the requirements of the LFPD IIPP in a fashion consistent with the hazards in that department. Develop knowledge and resources to understand and research department questions regarding California safety and health requirements within California Code of Regulations, Title 8. Assist in identifying safety resources, internet, outside speakers, or other means necessary to aid departments with meeting the requirements of this IIPP. Review periodically employee injury and illness trends. Bring injury and illness trends to the attention of the respective department manager and Fire Chief. Be available for employees to report safety hazards or injury exposures. Audit, or have audited, the department s hazards and compliance with this IIPP no less than annually. Report serious hazards, safety violations, or willful actions not meeting the intent of this IIPP to the Fire Chief. The Safety Officer for the Lakeside Fire Protection District is Humberto Lawler. Division Chief/ Manager Responsibility The duties and responsibilities of management personnel are: Ensure that the appropriate sections of the LFPD IIPP are implemented within their department. Develop department-specific job safety rules and requirements for the use of personal protective equipment. Develop department-specific safety communication methods. Review periodically employee injury and illness trends. Take any necessary preventive action to control the source(s) of these accidents. 4

5 Be available for employees to report safety hazards or injury exposures. Ensure that their department has an Emergency Plan that is designed with their department in mind and that employees are trained in the Plan. Serve as a contact for inspections of the department by Cal/OSHA, insurance company personnel, or other consultants. Captain/ Supervisor Responsibility The duties and responsibilities of Captains and supervisors are to: Implement an effective safety program, consistent with the requirements of LFPD IIPP and the needs of the department or work unit. Ensure that employees comply with safe and healthy work practices. Set a good example by following all safety rules, regulations, and policies. Instruct employees in safe work practices to be followed in daily work assignments. Educate employees regarding the proper personal protective equipment required for daily work assignments and ensure that the appropriate protective equipment is available for employees. Review medical, fire, and earthquake emergency response plans specific to the department and/or project. Inform and train employees in job safety and health practices involving hazardous substances used in the workplace. Initiate the investigation every accident or employee report of incident to determine cause, mitigation, and prevention. Perform periodic hazard inspections of the department equipment, facilities or work area. Hold periodic safety meetings with employees to present job-specific safety information and answer questions from employees regarding accident prevention. Maintain records of hazard inspection and correction, communication of safe and healthy work practices, discipline for a failure to follow safe work guidelines, and training. Do everything necessary to maintain a safe and healthful work environment. Employees Responsibility All Employees are responsible for ensuring their own safety, and the safety of others in the workplace by: Learning and following the standards, procedures, and safe work guidelines that applies to each job assignment. Discontinuing any specific activity that the employee feels or knows could lead to injury, illness, or damage to property. In such instances employees are responsible for promptly informing their supervisor or immediate superior and seeking guidance regarding the activity. 5

6 Wearing and using the prescribed personal protective equipment required for a job assignment or task. Bringing to their supervisor s attention any activity, behavior, or unsafe condition that could cause injury, illness to others, or damage to property. Reporting promptly to their supervisor any occupational injury or illness, or damage to property. COMPLIANCE Management is responsible for ensuring that all safety and health policies and procedures are clearly communicated and understood by all employees. Managers and supervisors are expected to enforce the rules fairly and uniformly. All employees are required to follow the safe work guidelines described within the Lakeside Fire Protection District (LFPD) Injury Illness Prevention Program (IIPP), the LFPD Safety Manual, LFPD Hazard Communication Program, LFPD Standard Operating Guidelines (SOGs), LFPD Safety and Health Program, participate in required safety and health training, wear required personal protective equipment, and follow all safety and health rules established by the LFPD. Our system of ensuring that all workers comply with the rules and maintain a safe work environment includes: Informing workers of the provisions of our IIP Program; Evaluating the safety performance of all workers; Recognizing employees who perform safe and healthful work practices; Providing training to workers whose safety performance is deficient; Disciplining workers for failure to comply with safe and healthful work practices COMMUNICATION The Lakeside Fire Protection District (LFPD) recognizes that open, two-way communication between management and personnel on health and safety issues is essential to an injury-free, productive workplace. The following system of communication is designed to facilitate a continuous and flexible flow of safety and health information between management and personnel in a form that is readily understandable and consists of one or more of the following: New worker orientation including a discussion of safety and health policies and procedures. Review of our IIP Program. Workplace safety and health training programs. Regularly scheduled Safety Meetings. 6

7 A labor/management Safety Committee. Tailboard (Tailgate) Meetings A system for workers to anonymously inform management about Workplace Hazards. Effective verbal communication of safety and health concerns between workers and supervisors, including translation where appropriate. Posting or distributing safety information. Such as posters, signs, tags, memos, , and bulletins. Safety Meetings General department safety meetings are one method that meets the safety communication requirement. This method requires each division to have periodic, department-wide, employee meetings at which employee safety and health is one topic. Such meetings are not to be held less than semi-annually when used to meet this standard. These meetings can include any of the following: Discussion of safety and health issues specific to department operations, present safe work practices, or a project that has specific safety and health exposures. Presentation of videos or films illustrating and employee safety and health topics. Outside speakers on employee safety and health topics. Management presentation of existing, new, or revised safe work practices required in preventing employee injury or illness. Solicitation from employees of safety and health issues of concern to them. Record of these meetings, topics discussed, and attendance is required. Safety Committee Membership on the Safety Committee should include a balanced representation. Representation shall consist of the Fire Chief, or designee, safety officer, and labor representatives from Lakeside Fire Protection District (LFPD). Other members may be asked to serve at the discretion of the Safety Committee and/or the Fire Chief. See the Safety Committee/ Accident Review Board policy in the LFPD Policy and Procedures (Lexipol). The safety committee, if used to meet this safety communication requirement, shall not meet less than quarterly. The safety committee reviews safety topics and establishes action plans at each meeting to address improvements to employee safety or health, physical deficiencies, or safe work practices, if any. Hold meetings on a regularly scheduled basis not to exceed four months, or as needed; distribute meeting agendas, pertinent reports and previous minutes to committee members. 7

8 Review all accidents involving Fire Department vehicles and make a determination as to whether the accident is Preventable or Non Preventable. In cases of occupational illness, industrial accidents involving injury, or alleged hazardous conditions, make recommendations to the Fire Chief for prevention of similar occurrences in the future. Review safety related departmental policies and procedures and make recommendations to the Fire Chief. Review department accident and injury reports and related information; make recommendations for reducing accident and injury rates. Review results of the periodic scheduled inspections Reviews investigations of alleged hazardous conditions brought to the attention of any committee member. When determined necessary by the committee, it may conduct its own inspection and investigation to assist in remedial solutions. Make recommendations based on laws, regulations, and department needs for improving or changing personal protective equipment used by fire department employees. Review and disseminate safety information to managers, supervisors and employees. Provide recommendations, guidance, assistance and support health and safety programs and to assist in the evaluation of employee safety suggestions. Keep records of meetings and agendas. The results of the safety committee meetings, and any action taken by the committee, are posted for employees on the Safety Bulletin Board. Minutes of these meetings, topics discussed, corrective action, and attendance is required. The committee may utilize the Safety Committee Minutes form or department approved methods. Safety committee minutes shall be kept for a minimum of 1 year. Tailboard (Tailgate) Meetings Departments often utilize tailgate meetings when crews are working at different work sites on a daily or weekly basis. Tailboard meetings are brief, formal or informal discussion of crew safety. Tailboard meetings are best when they are led by the foreman or supervisors and include a discussion of that week s or day s activity, hazards, and accident prevention critical to the safety of performing the tasks discussed. Departments choosing this form of safety communication hold the meetings no less than every ten working days. Supervisors may utilize the Tailboard Safety Meeting Report form. Workplace Hazards Employees are encouraged to report previously unrecognized hazards that could cause injury, illness, or death of an employee or to a member of the public, or damage to property. Employees may utilize the Hazard Report form. Employees may report hazards to their supervisor or manager and expect that the hazard will be evaluated and abated; consistent with the potential it creates. Should an employee 8

9 not feel comfortable in reporting the hazard to their supervisor/ manager, they may report it to the Safety Officer. Employees may report hazards without fear of reprisal and may also report hazards anonymously. Whenever an employee reports a hazard, it will be evaluated with regard to the potential injury or illness it creates. Based upon this evaluation, the hazard may be abated immediately, temporary measures may be taken until the hazard is abated fully, or the hazard may be scheduled for future abatement. The employee reporting the hazard will be informed of the outcome of their hazard report. Postings Lakeside Fire Protection District (LFPD) stations, administration office, and annex maintain bulletin boards with occupational safety and health information. Safety and health information posted on this bulletin board consist of the following: Permanent Postings Cal/OSHA Poster, Safety & Health Protection on the Job. Workers Compensation Notice regarding current insurance carrier and employee rights. Emergency Evacuation Map and Emergency Response Information. Temporary Postings Annual OSHA Statistical Report. Annually the Cal/OSHA Form 300 will have the statistical summary portion posted for employee review. Safety Committee results, if applicable Safety Promotional Information Safety Posters. Any other pertinent safety communication not required to be more urgently communicated. The safety bulletin boards may be used for safety memos and other non-critical information regarding safety, safety meetings, and minutes from safety meetings. HAZARD ASSESSMENT Hazard identification and safety inspections are the responsibility of all employees. Managers and supervisors of each station or work area are responsible to identify and abate employee safety and health hazards. Periodic inspections and assessments to identify and evaluate workplace hazards methods include: Daily Inspections are visual inspections of all station and office work areas, shop area, apparatus pre-trip inspections, equipment, Personal Protective Equipment (PPE), and other safety equipment. Observe for general hazards and deficiencies. 9

10 Weekly Inspections include apparatus checkouts and general workstation inspections. Quarterly Inspections include apparatus, equipment, stations, shop, offices, and annex buildings. Facility and equipment inspections are conducted by the supervisors using the Self Inspection Checklist. Annual Inspections include apparatus and facilities. Annual safety inspections are conducted by the Safety Officer and the Fleet Maintenance Supervisor using the Self Inspection Checklist. In addition periodic inspections are performed: When we initially established our IIP Program; When new substances, processes, procedures or equipment which present potential new hazards are introduced into our workplace; When new, previously unidentified hazards are recognized; When occupational injuries and illnesses occur; When we hire and/or reassign permanent or intermittent workers to processes, operations, or tasks for which a hazard evaluation has not been previously conducted; and Whenever workplace conditions warrant an inspection Periodic inspections consist of identification and evaluation of workplace hazards utilizing applicable sections of the attached Hazard Assessment Checklist (Self Inspection Checklist), Identified Hazards and Correction Record and any other effective methods to identify and evaluate workplace hazards. ACCIDENT/INJURY/ EXPOSURE INVESTIGATION and REPORTING All injuries and illnesses arising from, or in the course of, employment with the Lakeside Fire Protection District (LFPD) are reported immediately to the appropriate supervisor. The supervisor and injured employee follow the LFPD specific injury and illness response procedures outlined in the LFPD Policy and Procedures Manual (Lexipol). This will include:* Communicable Disease Exposure Report Form (County of San Diego Form) LFPD Reportable Non-Medical Exposure Form FAIRA Vehicle Accident Reporting Kit (Forms) Workers Compensation Forms Packet (Intercare) *These forms are available through the LFPD web site, duty chief, and or administration office. 10

11 Accident/ Injury investigation is utilized as one method for identifying previously unrecognized hazards. The investigation identifies the probable causes and prevention of the accident. Procedures for investigating workplace accidents and hazardous substance exposures include: Visiting the accident scene as soon as possible; Interviewing injured workers and witnesses; Examining the workplace for factors associated with the accident/exposure; Determining the cause of the accident/exposure; Taking corrective action to prevent the accident/exposure from reoccurring; and Recording the findings and corrective actions taken Investigation / Corrective Action Report. Questions to ask in an Accident/Exposure Investigation should include: What happened? Why did the accident happen? What should be done? What action has been taken? OSHA 300 Log of Occupational Injuries and Illness The Lakeside Fire Protection District (LFPD) maintains an OSHA 300 Log of Occupational Injuries and Illnesses. The instruction and definition of recordable injuries and illnesses to be recorded are on the back of the Log itself. This Log is kept by calendar year. At the end of each calendar year the log is totaled and signed by the Administrative Service Manager. Prior to February 1 of each year, the right side of the Log is posted on the safety bulletin board(s) for employee information regarding recordable injuries and illnesses. Each Log is kept as a record for five years. HAZARD CORRECTION Unsafe or unhealthy work conditions, practices or procedures shall be corrected in a timely manner based on the severity of the hazards. Hazards shall be corrected according to the following procedures: When observed or discovered; When an imminent hazard exists which cannot be immediately abated without endangering employee(s) and/or property, we will remove all exposed workers from the area except those necessary to correct the existing condition. Workers necessary to correct the hazardous condition shall be provided with the necessary protection; and All such actions taken and dates they are completed shall be documented on the appropriate forms. 11

12 TRAINING/ INSTRUCTION All workers, including managers and supervisors, shall have training and instruction on general and job-specific safety and health practices. Training and instruction shall be provided as follows: When the IIP Program is first established; To all new workers; To all workers given new job assignments for which training has not previously provided; Whenever new substances, processes, procedures or equipment are introduced to the workplace and represent a new hazard; Whenever we are made aware of a new or previously unrecognized hazard; To supervisors to familiarize them with the safety and health hazards to which workers under their immediate direction and control may be exposed; and To all workers with respect to hazards specific to each employee's job assignment. Some of the workplace safety and health practices our employees will be trained on include, but are not limited to: Explanation of our IIP Program, emergency action and fire prevention plans, and measures for reporting any unsafe conditions, work practices, injuries and when additional instruction is needed. Use of appropriate clothing, including gloves, footwear, and personal protective equipment. Information about chemical hazards to which employees could be exposed and other Hazard Communication Program information. Provisions for medical services and first aid including emergency procedures Our Workplace Code of Safe Practices. Good housekeeping and fire prevention. Safe procedures for cleaning, repairing, servicing and adjusting equipment and machinery. Safe access to working areas. Protection from falls. Electrical hazards, with particular awareness of working around wet locations. Machine, machine parts, and prime movers guarding. Lock-out/block-out procedures. Materials handling. Power tools and chain saw operation. Driver safety. Slips, falls, and back injuries. Ergonomic hazards, including proper lifting techniques and working on ladders or in a stooped posture for prolonged periods at one time. Personal protective equipment. 12

13 Respiratory Equipment. Hazardous chemical exposures. Hazard communication. Physical hazards, such as heat/cold stress, noise, and non-ionizing radiation (such as microwaves). Bloodborne pathogens and other biological hazards. In addition, we provide specific instructions to all workers regarding hazards unique to their job assignment, to the extent that such information was not already covered in other training. See Cal OSHA List of Training Subjects. RECORD KEEPING Employee safety training is documented in the Lakeside Fire Protection District (LFPD) training report program such as Firehouse and Target Solutions. The OSHA List of Training Subjects checklist, Worker Training and Instruction Record and Employee Safety Training Verification shall also be utilized. List of Training Subjects records shall be maintained for a minimum of 3 years from the date on which the training occurred. Documentation shall also include: Course content. Course handouts. When the training was conducted. Attendance roster (readable). Instructor s name and title. Any additional training on the same topic and its schedule. Safety meeting and Safety Committee minutes, work place hazard inspections, and other reports are kept for a minimum m of 1 year. OSHA 300 Log of Occupational Injuries and Illness will be maintained for a minimum of 5 years. OTHER PROGRAMS In addition to the Lakeside Fire Protection District (LFPD) Illness and Injury Prevention Program (IIPP), personnel shall also refer to and utilize: Lakeside Fire Protection District Policy and Procedures Manual (Lexipol) Lakeside Fire Protection District Safety Manual and Standard Operating Guidelines (SOG) Fire Agencies Insurance Risk Authority (FAIRA) Risk Management Manual Respiratory Protection Program Exposure and Infection Control Program 13

14 Hazard Communication Program Heat Illness Prevention Plan Emergency Action Plan Fire Prevention Plan Hazardous Materials Business Plan (HMBP) Spill Prevention Control and Countermeasures Plan (SPCC Plan) Medical Waste Management Plan (MWMP) Storm Water Best Management Practices (SWBMP) GENERAL SAFE WORK PRACTICES It is the employees responsibility to follow safety rules and to use required safety equipment. Below are general safety rules that employees will follow: 1. Good housekeeping is practiced at all times. Clean up all waste and eliminate injury or illness exposures in work areas. 2. Suitable clothing and footwear must be worn at all times. Personal protection equipment (hardhats, face, hand, hearing protectors, dust masks, and eye protection) are worn whenever required by the hazard or job requirement. 3. All employees participate in safety meetings conducted periodically. 4. Anyone under the influence of intoxicating liquor or drugs, which might impair motor skills and judgment, shall not be allowed in the workplace and are subject to termination. 5. Horseplay, scuffling, and other acts, that have an adverse influence on safety or well-being of other employees, are prohibited. 6. Work shall be well planned and supervised to prevent injuries in the handling of materials and in working with equipment. 7. No one is permitted to work while the employee's ability or alertness is so impaired by fatigue, illness, or other causes that it might expose the employee or others to injury. 8. Employees should check to see that all guards and other protective devices are in proper places and adjusted, and shall report deficiencies promptly to their supervisor. 9. Employees shall not handle or tamper with any electrical equipment, machinery, air or water lines in a manner not within the scope of their duties, unless they have received instructions from an authorized source. 14

15 10. All injuries should be reported to the supervisor so that arrangements can be made for medical or first aid treatment. 11. When lifting cartons or heavy objects, use the large muscles of the leg instead of the smaller muscles of the back. 12. Do not throw things, especially material and equipment. Dispose of all waste properly and carefully. 13. Do not wear shoes with thin or torn soles. 14. When job conditions change, so do the hazards; therefore, each worker should anticipate new hazards and plan their avoidance. 15. All new hazards should be brought to the attention of the supervisor. 16. Each worker should develop a daily routine of checking his/her job area for any potential hazards or deficiencies. 17. All defective tools should be brought to the attention of the supervisor. 18. Each employee should provide suggestions concerning safety to his or her supervisor. 19. All employees should familiarize themselves with the location of first aid equipment. 20. Use a ladder when required. Do not use the top two - (2) rungs. Do not climb on other objects to reach heights. 21. All emergency equipment such as fire extinguishers and fire alarms must be properly identified and maintained. 22. Know the location of fire and safety exits. All exit doors must be kept clear of obstacles. 23. Each employee is expected to be responsible for his/her own safety and at the same time to exercise care in avoiding injury to his/her fellow workers. 24. Be sure that all tools are maintained in a good state of repair. 25. No employee should use chemicals without fully understanding their toxic properties and without the knowledge required to work with these chemicals safely. 15

16 FORMS Acknowledgement of Lakeside Fire Protection District Policy Safety Committee Minutes Tailgate Safety Meeting Report Action Regarding Inspections, Reports, Injury Trends Hazard Report Self-Inspection Checklist (Hazard Assessment Checklist ) Identified Hazards and Correction Record (Identified Hazards and Correction Record) Investigation/Corrective Action Report (Investigation / Corrective Action Report.) Employee Safety Training Verification List of Training Subjects (List of Training Subjects) Work Training and Instruction Record (Worker Training and Instruction Record) Employee Incident Report Communicable Disease Exposure Report Form (County of San Diego) ( LFPD Reportable Non-Medical Exposure Report ( FAIRA Vehicle Accident Reporting Kit (Forms) ( Workers Compensation Forms Packet (Intercare) ( Identified Hazards and Correction Record 16

17 ACKNOWLEDGEMENT OF DISTRICT SAFETY POLICY I have read and understand the Injury and Illness Prevention Program (IIPP) and safety procedures of the District. I agree to abide by them. I understand that violation of these policies and procedures can result in disciplinary action, up to, and including termination. Employee Signature Date Supervisor Signature Date Original: Copy: Personnel File Employee 17

18 Safety Committee Minutes Date: Chair: Committee Members Present Outstanding Business 1 Issue Responsible Party Completion Date Status New Completion Date Employee Injury Trends Source Current Month Qtr. To Date Year To Date

19 TAILGATE SAFETY MEETING REPORT Date: / / Work Site: 1. Safety Areas Discussed: a) b) c) 2. Previous week review of Safe Practices and Job Conditions: a) b) c) 3. Action Taken to Correct Unsafe Practices and Conditions: a) b) c) 4. Injuries Reported: a) Date: Time: AM/PM Injury: b) Date: Time: AM/PM Injury: 5. Job Conditions & Equipment Inspected: a) b) c) Inspected By: Attended By: Employee s Signature

20 Action Regarding Inspections, Reports, Injury Trends Issue: Action Plan: Responsibility: Date Due: Issue: Action Plan: Responsibility: Date Due: Issue: Action Plan: Responsibility: Date Due: Issue: Action Plan: Responsibility: Date Due: Issue: Action Plan: Responsibility: Date Due:

21 HAZARD REPORT Instructions: Employees may use this form to report hazards in the workplace. They are not required to sign this form unless they wish. These forms are to be turned in to the department supervisor or manager. If the employee believes, or has knowledge that this act will not correct the hazard, they may turn them in to the human resources representative for the District. You do not need to fill out the italicized columns. Supervisors or Managers: When you receive notification of hazard(s) by employees, you are required to correct the hazard and communicate that to affected employees. If correction can not be preformed immediately upon notification the supervisor or manager is required to take intermediate steps to protect employees, such as temporary engineering changes, red-tagging equipment, providing additional personal protective equipment, or similar. Fill out the italicized columns. Department or Location Date Employee Name (Optional) Department Supervisor Substance, Equipment, Process, Practice or Work place Condition Suggestion(s) To Correct Hazard Action Taken

22 EMPLOYEE SAFETY TRAINING VERIFICATION Department: Employee's Name & ID: Hire Date: Training Program Job Classification: Date Completed Instructor Comments

23 Employee Name: Accident Description: EMPLOYEE INCIDENT REPORT An employee incident report is not designed to find fault or blame. It is an investigation to determine the contributing causes (there is almost always more than one) that led to the incident. When performed correctly, the report will help identify how to prevent future incidents. Date of Incident: Time of Incident: AM/PM Date Reported: Job Title: Length of time the injured employee is in job position (circle one) Department or Occurrence Location: 0-6 Months 7-12 Months Months 25 + Months Source of Incident: Lifting materials, equipment, or tools Carrying materials, equipment, or tools Repetitive motion from lifting, carrying or use of tools or equipment Repetitive motion from computer operation Slip and fall on water, grease, or fluids on floor Trip and fall over object Trip but no fall Fall from height, ladder, or elevated work platform Needle or sharps injury from contaminated object Cut or puncture from uncontaminated sharp objects such as knife, hand tools, etc. Pinched by or between objects Struck by flying or moving objects Struck against stationary object Fluid or object in the eye Exposure to chemicals Struck, attacked, or injured by other person Other (Describe) Cause Of Incident - There may be more than one. Did not follow safe work practice There is no safe work practice Did not understand how to perform task Safe practice was not communicated List the following that contributed to causing the incident (more than one may apply): Unsafe Acts: Unsafe Conditions: Unsafe Equipment: Is there any reason to question the authenticity of this injury? Yes No Why? Equipment was not available or working Not comfortable using equipment Employee failed to recognize hazard Tool or equipment failed Act of other employee or person What Has, Or Should Be Done, To Prevent Recurrence: Completed By: Reviewed By: Name Name Position Position Date: Date: AcceptableRisk