Pierce College Accident Reporting Form
Attention: Campus Safety, 9401 Farwest Drive SW, Lakewood, WA 98498 Instructions: Any person involved in an accident must complete Part 1 entirely and turn it in to Campus Safety (with a copy to their supervisor) within 24 hours of accident. Supervisors must turn in Part 2 within 5 working days. PART 1: Please check the boxes that apply. Type of Report: Status:
Personal Injury
Motor Vehicle Incident Visitor
Medical Emergency
Other: ______
Employee (Staff / Faculty)
Student
Other: _________ / AM PM Puyallup
Name: Local Address: Phone (work): Phone (home):
Date of Accident: / Time of Accident: : Campus: Fort Steilacoom Other: Building/Floor/Room:
Did someone witness the accident? Witness 1: Witness 2: ***Witnesses must complete a Witness Statement Form.*** Describe the accident: Describe the event leading up to the accident:
Ph: Ph:
How did the accident happen?
Describe the object/exposure/activity/event that inflicted the injury/illness/damage:
Accident Response: Did you receive medical treatment? No / First Aid / Paramedics / ER / Doctor / Hospitalized Date/Time of Initial Treatment: / / : AM / PM Did you miss work? Yes / No If Yes, how much work did you miss? Are you on doctor-ordered restrictive duty? Yes / No If Yes, for how long? (Continued on other side)
Injury Information: Please check the boxes that apply.
X What part of the body is affected? Abdomen Ankle (s) Arm (s) Back (lower, middle) Back (upper) Buttocks Chest (includes ribs) Ear (s) external Ear (s) internal Elbow (s) Eye (s) Face Finger Foot Groin Hand (s) Head Hip Jaw Knees (s) Lips Neck Nose Respiratory System Shoulder (s) Toe Tongue Tooth Wrist (s) Other: Not Applicable Left/ Right X What is the nature of the injury? Abrasion Bite Broken Bruise Burn – Chemical/radiation Burn - Thermal Carpal Tunnel Syndrome Choking Concussion Cut Dermatitis Dislocation Electric Shock Foreign Body Fracture Hearing loss Heat Injury Heat Stroke Irritation/inflammation Laceration Multiple Injuries Pinch Pre-existing Condition Puncture Repetitive Trauma/Injury Scratched Sliver Sting Strain/Sprain Other: Not Applicable X What were the contributing causes? Absorption Alcohol Animal Bypassing Safety Device Caught in/under/between Collision Lack of Communication Distracted Eating Excessive Noise Exposure/Contact Facilities/Equipment Horseplay Lifting/Pushing In a hurry Inadequate instruction Inattention to surroundings Inhaling/Swallowing Motor Vehicle Overexertion Poor Housekeeping Poor Lighting Poor Procedures Repetitive Motion Slip/Trip/Fall Struck against/by Training Unsafe act Unsafe equipment Unsafe clothing/shoes Other: Not applicable X What were the conditions during the incident? Carpeted Surface Cement Surface Confined Space Design/Arrangement Distraction Fire Environmental Dust/Gas/Vapor Excessive Exposure Defective tool/equipment Grass Hazardous Material Inadequate Barriers Inadequate Warning Systems Liquid spill Obstructions Pavement Poor Lighting Poor Housekeeping Rocks/Gravel Slippery surface Tile Surface Weather – Fog Weather – Hot Weather – Icy Weather – Rain Weather – Snow Wet Surface
Other: Not applicable
I verify this information is true and correct. I understand my responsibility to turn this completed form into the Campus Safety office (with a copy to their supervisor) within 24 hours of accident. ____________________________________________ _________________________ Signature Date For Official Use Only: Received by: Date: Copied to:
Supervisor’s Accident Investigation Report
Attention: Pierce College Campus Safety, 9401 Farwest Drive SW, Lakewood, WA 98498
PART 2: INVESTIGATION INTERVIEW & CHECKLIST: (Questions to ask the person involved with the incident. Please complete or circle appropriate responses.) Name of Injured Person: _____________________________________________ Date/Time of Accident: ______________________________________________ Date/Time Accident Reported to Supervisor: ______________________________________________ Incident / Injury: How do you think the incident / injury happened and what were you doing at the time? __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ How long had you been on-shift prior to the incident / injury? ___________________ How long had you been working on this task? ______________________ Is this task part of your normal duties? Have you been instructed / trained in this task? Yes Yes No No
What were you doing in the time prior to the incident / injury? __________________________________________________________________________________________________ __________________________________________________________________________________________________ Are there any other factors involved (schedule, environment, equipment, maintenance, individual, etc.)? __________________________________________________________________________________________________ __________________________________________________________________________________________________ What do you think could have been done to prevent this incident from occurring? __________________________________________________________________________________________________ __________________________________________________________________________________________________ Any other comments or observations? __________________________________________________________________________________________________ __________________________________________________________________________________________________
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Please circle the most appropriate response/s: What sort of incident/injury occurred? manual labor / repetitive motion / cut / bruise / burn / fall / slip / trip / sprain / fracture / vehicle / chemical / insect / animal / foreign body / stress/ other: Location where incident occurred? Type of injury: sting / bite / kick / puncture / strain / sprain / chemical / slip / trip / fall / other: Standard operating procedures followed? Yes / No / N/A Identification of equipment/object/insect involved:
Equipment in good condition? Yes / No / N/A Date of last service of equipment: Appropriate safety equipment and/or Personal Protective Equipment (PPE) used? Yes / No / N/A If no, why not? Lighting adequate? Yes / No / N/A Housekeeping issues contributed? Yes / No / N/A Confined space? Yes / No / N/A Surface type: cement / tile / grass / dry / wet / damaged / torn / sand / footpath / carpet / gravel / rocks / pavement / rug / ladder / other: Type of shoes worn: open-toe / closed-toe / steel-toe / boots / heels / pumps / sandals / none / other: Workload excessive? Yes / No / N/A Workload boring and repetitive? Yes / No / N/A If it was a slip or trip: Height of fall /slip / trip? Were you running / walking / turning a corner / jumping / other? If stairs, going up / going down? Did you fall on your front / back / side? What were you carrying (if anything) at the time? If the incident involved chemicals: Was an MSDS (Material Safety Data Sheet) available? Yes / No Disposal / handling / storage of chemical product adequate? Yes / No / N/A If the incident involves manual labor: Were work items within easy reach? Yes / No / N/A Ergonomic equipment available? Yes / No / N/A Was the equipment being used correctly? Yes / No / N/A Repetitive and/or forceful movements used? Yes / No / N/A Action involved: reaching / bending / stooping / sitting / kneeling / twisting / pushing / pulling / lifting / catching / lowering / carrying Weight of object? Distance carried/ position of object moved from/to? Height of load? If the incident involves a vehicle or bicycle: traffic conditions: Weather conditions: dry / wet / foggy / night / day Intersection / turning right or left / driveway / straight road Speed prior to accident? Traveling: to work / lunch time / after work / to course / work related travel Any other factors involved?
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Investigator’s comments and observations __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ RECOMMENDATIONS: A hierarchy of control should be used to assist with the prevention of future similar injuries. The ‘hierarchy of control’ depicts the most to the least effective methods, as shown in the table below. This is the most important part of the investigation process! Do not leave blank.
Risk Control Options
Elimination – Do you have to do the task? Substitution – Is there another way you can do the task?
Action Required
By Whom By When
Engineering – Can you use tools or machinery to make the job safer? Administration – Can you improve work practices? (E.g. limit time of exposure). Use of Personal Protective Equipment (PPE) – i.e. safety glasses, reflective vests, etc. OR Safety Equipment – i.e. safety cones, caution tape, warning signs Date feedback provided to person reporting the injury/incident: Signed: Position: Print Name:
/
/ Ph: Date: / /
Office Use Only
(Safety and Health Office Recommendations)
Received By:
Date Part 2 received:
Date Completed:
Date Reviewed by Safety Committee:
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