FAIRBANKS NATIVE ASSOCIATION
CONSUMER/EMPLOYEE/VISITOR INCIDENT REPORT

Complete and submit Section I to the Program Supervisor and email a copy to the FNA H & S Coordinator () within 24 hours. Additionally, the Program Supervisor is to notify appropriate agencies or authorities as required by law, grant, and contract or otherwise.

Report submitted by:
Title: / Date: Click here to enter a date.
Telephone Number: / Extension:
Date of Incident: Click here to enter a date. / Time/Shift: Choose an item.
Address/Location of Incident: Choose Location
Other:

SECTION I – Description of the Incident

a)Type of Incident: Choose from drop-down

Choose an item.

If Other, please describe:

Click here to enter text.

b)Name each person involved in the incident (use initials for consumer(s) if 42 CFR Part 2 applies). Indicate the role of each person in the incident using the following abbreviations:

C=ConsumerE=EmployeeV=VisitorW=Witness (if not already identified)

Name / Role / Comments/Notes

c)Describe how the incident/event occurred:

Click here to enter text.

d)Name and position of person that was immediately notified:

e)Supervisor’s instruction(s) (if applicable):

Click here to enter text.

Additional Comments:

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Signature: ______Date: ______

Emailed to H & S (as soon as possible and within 24 hours (Date/Time): ______

Note: If this incident involves an injury to an employee, please have the staff member contact Medcor at 1-800-553-8041.

If this is a vehicular accident, please fill out a vehicle accident report as well.

SECTION II – Department or Supervisor In Charge of Investigation

(Send Section I and Section II to the program safety representative)

  1. Was the incident preventable? ☐Yes ☐ No If yes, how?


  1. Did the employee take action after the incident? ☐ Yes ☐ No If yes, what action was taken?
  1. What action was taken to prevent future similar incidents?
  1. What follow up is needed?
  1. Who is responsible for follow up?
  1. Additional information: (Action taken)

Your name: ______Date: ______

(Please Print)

Your signature: ______

Date & Time Reviewed by Program Director: ______

SECTION III – Program Health & Safety Representative Review/Follow-up:

IMMEDIATE CAUSES – check all as appropriate
Substandard Acts/Actions
☐Operating equipment without authority
☐Failure to warn
☐Failure to secure
☐Operating at improper speed
☐Making safety devices inoperable
☐Removing safety devices
☐Using defective equipment
☐Failure to use PPE
☐Improper loading
☐Improper placement
☐Improper lifting
☐Improper position for task
☐Servicing equipment in operation
☐Horseplay
☐Under influence of alcohol and/or other substances / Substandard Conditions
☐Inadequate guards or barriers
☐Inadequate or improper protective equipment
☐Defective tools, equipment or materials
☐Congestion or restricted action
☐Inadequate warning system
☐Fire and explosion hazard
☐Poor housekeeping, disorder
☐Hazardous environmental conditions, gases, smoke, dusts, fumes
☐Noise exposure
☐Radiation exposure
☐High or low temperature exposure
☐Inadequate or excess illumination
☐Inadequate ventilation

Comments:

Click here to enter text.

______

Program Health & Safety RepresentativeDate

______

Program DirectorDate

______

Division DirectorDate

______

Executive DirectorDate

______

Health & Safety CoordinatorDate

NOTE: Send completed original Incident Report to Health and Safety Coordinator

Incident Report FormRevised September 1, 2016

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