Incident Investigation Procedure (PDF)

FACILITIES SERVICES INCIDENT INVESTIGATION(All fields must be completed within 48 hours of incident)Date of Incident: ________________________________ Time of Incident: ___________________________Name of Employee(s) Involved: _________________________________ Penn ID#: _____________________Job Title: _________________________________ Contact Number for Employee(s): ____________________Location of Incident (Building/Room Number): ___________________________________________________Was Employee working alone? £ Yes £ NoIf no, with whom? ________________________________Supervisor’s Name: _________________________________________________________________________Manager’s Name: __________________________________________________________________________Describe Injury or Illness: ____________________________________________________________________Did Employee(s) Receive Medical Treatment? £ Yes £ NoIf yes, Where: ________________________________________When: ______________________________Physical Damages: __________________________________________________________________________Incident Description: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Factors Contributing to the Incident: (include weather when appropriate.) ________________________________________________________________________________________________________________________Protective Equipment: (Answer “Y” for yes, “N” for no and “N/A” for not applicable.)Worn Available Worn AvailableGloves ________ ________ Protective Clothing ________ ________Safety Glasses ________ ________ Rubber Boots ________ ________Goggles ________ ________ Slip Resistant Shoes ________ ________Face Shield ________ ________ Steel Toe Shoes ________ ________Respirator ________ ________ Other ___________ ________ ________Hard Hat ________ ________ Other ____________ ________ ________What tools or equipment were being used? (Specify.)£ Power Tools ____________________________ £ Hand Tools ___________________________________£ Ladder ________________________________ £ Scaffolding ___________________________________£ Other __________________________________________________________________________________

What procedures were being used? (Check all that apply.)£ Lockout/Tagout £ Confined Space Entry £ Other _____________________________If lifting was involved, what was being lifted? Specify: __________________________ Weight: ___________Actions Taken to Prevent Reoccurrence: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Supervisor who Perform Report: __________________________Manager who Reviewed Report: __________________________Date: ______________Time: ___________Date: ______________Time: ___________Director who Reviewed Report: ___________________________ Date: ______________ Time: ___________Copy Sent To EHRS _______________________________Date: ___________________Comments received from EHRS on the Incident Report findings:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Date EHRS Comments Received: _____________________Copy Sent to FES __________________________________Date: ___________________Comments received from FES on the Incident Report findings:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Date FES Comments Received: _____________________