PERSON INITIATING THIS REPORT
Name: / Email: / Phone:
Position: / Department:
Date Reported: / Time of Reporting: / AM / PM
Signature:
PERSON INVOLVED OR AFFECTED
Name: / Email: / Phone:
Role: / Employee / Volunteer / Client / Other (describe):
Parent/Guardian Signature (if person involved is under 18 years of age):
INCIDENT DETAILS
Date of Incident: / Time of Incident: / AM / PM
Hopelink Site/Location: / Specific Location of Incident:
Describe what led up to the incident and what happened, using “IP” for the involved party instead of using the involved/affected person’s name (use additional page if necessary):
First Aid Provided? Yes No NA / By Whom? / What Type?
CLASSIFICATION (Select a level and select an item in that section)
Level 1 / Level 2 / Level 3 / Level 4
Near miss (No incident occurred but could have)
Property damage
Injury, no first aid required
Injury requiring first aid
Loss of consciousness
Other (describe): / Injury requiring medical treatment / Client incident involving police or fire department response
Workplace violence
Fire or explosion
Theft
Client escalation / Death
In-patient hospitalization
Amputation
Loss of eye
(Go to level 4 if in-patient hospitalization or amputation occurred)
TYPE OF INCIDENT (Select at least one item for each section; multiple items can be selected)
Type of Injury / Area of Injury / Cause of Injury or Damage
Abrasion/contusion
Allergic reaction
Animal/insect bite
Burn
Cut/ laceration
Exposure to potentially biohazardous material
Fracture, dislocation
Hearing loss
Loss of consciousness
Mental, emotional distress
Pain, irritation, inflammation, swelling
Puncture/needlestick
Rash, dermatitis
Sprain, strain, twist
None
Property damage
Other (describe): / Head
Face
Eyes
Neck
Arms
Hands
Back
Chest
Legs
Feet
Internal
Skin
None
Other (describe): / Animal/ insect
Biohazardous (infectious) materials
Chemicals
Electricity
Ergonomic issues
Fall from height (6’ or +)
Fall of less than 6’; or on stairs)
Fire, explosion
Flood, wind, etc.
Glass/splinter/edge, etc.
Human behavior
Involved in/saw upsetting event
Machinery
Motor vehicle, bicycle, etc. / Needles, medical sharps
Noise
Overexertion
Plants, vegetation
Slip or trip (no fall)
Struck/pinched by moving object
Structures, surfaces
Temperature extreme (hot or cold)
Tools, including box cutters, knives
Ventilation; indoor air quality issues
Violence
None
Other(describe):
POSSIBLE FACTORS (Select at least one item; multiple items can be selected within and among the sections)
Policies/Procedures / Human Factors / Equipment / Environment
Failure to follow procedures
Appropriate procedures non-existent
Inadequate instructions, procedures
Inadequate planning, preparation Inadequate support, assistance
Other (describe): / Inadequate training
Improper PPE
PPE not used
Improper lifting
Failure to follow procedures
Verbal assault
Physical assault
Inattention
Loss of balance
Rushing
Phobia, anxiety
Horseplay
Other (describe): / Defective tools, equipment
Defective material
No guards, barriers
Inadequate guards, barriers
Improper use of equipment
Inadequate maintenance
Improper equipment
Other (describe): / Animal/insect action
Inclement weather
Slippery, uneven surface
Ergonomic issues
Sharp objects
Hot objects
Frostbite
Heat stress
Inadequate ventilation
Inadequate illumination
Air contaminants
Chemicals
Noise
Fire, explosion
Poor housekeeping
Other (describe):
SUGGESTED CORRECTIVE ACTIONS BY PERSON INVOLVED OR AFFECTED
Provide safety training / Undertake hazard assessment / Submit request for maintenance/repair
Change work area layout/design / Change/review work procedures / Provide PPE
Other (describe):
/ Stop here. Submit the completed form(s), any attachments, and any video/photos to yoursupervisor and the Safety and Risk Manager within 24 hours of the incident. /
SUPERVISOR
Name: / Email: / Phone:
Signature: / Date: / Person(s) notified:
Possible Causes (Consider all the factors that may have contributed to the incident, including equipment, policies, procedures, and personnel. Please use “IP” for the involved party instead of using the involved/affected person’s name.):
Recommendations/Preventive Measures:
Comments:
SAFETY & RISK MANAGER
Date Entered into Incident Reporting Files: / Tracking #:
Investigation Required? / Yes No NA / Investigation Complete Date:
Corrective Action Required? / Yes No NA / Corrective Action Complete Date:
Forwarded to: / Director/AD/VP: / Human Resources / Facilities
Other: / Volunteer Manager / CFO
Last Updated: 12/6/2017 Page 2