Incident Report Form - Department of Physics - Ryerson University

Ryerson University AIE Internal Report Page 1 of 4RYERSON UNIVERSITYINTERNAL ACCIDENT/INCIDENT/EXPOSURE (AIE) REPORTOriginal Completed Report (4 pages) to be sent to the CEHSM, 11th Floor, Jorgenson HallINJURY FACULTY D A T E T I M E Control NumberPROPERTY DAMAGESTAFFEXPOSURE Day/Month/Year Hrs./Mins. A.M./P.M.INCIDENT (Near Accident)Building / Room / Location of Incident:Person Involved:Supervisor's NameDept/ProgramDept/Program(C I R C L E A P P R O P R I A T E N U M B E R (S) I N A L L C O L U M N S)TYPE OF CONTACT TYPE OF INJURY PART OF BODY01 Struck Against (Running or Bumping into) 01 open wounds and lacerations RIGHT SIDE LEFT SIDE02 Struck By (Hit by Moving Object) 02 bruising 01 head and neck 01 head and neck03 Fall to Lower Level 03 foreign bodies in various sites 02 eyes 02 eyes04 Fall on Same Level 04 crushing injuries 03 ears 03 ears(Slip and Fall, Trip Over) 05 sprains and strains 04 nose 04 nose05 Caught In (Pinch and Nip Points) 06 fractures and dislocations 05 teeth 05 teeth06 Caught On (Snagged, Hung) 07 internal injuries 06 back and spinal column 06 back and spinal column07 Caught Between or Under 08 burns and scalds 07 chest 07 chest(Crushed or Amputated) 09 amputations 08 abdomen 08 abdomen08 Contact With ( Electricity, Heat, Cold 10 concussion 09 buttocks and pelvis 09 buttocks and pelvisRadiation, Caustics, Toxics, Noise, Sharps) 11 asphyxiation or poisoning 10 hip 10 hip09 Overstress; Overexertion; Overload by gas or fumes 11 thigh 11 thigh12 asphyxiation other than 12 knee 12 kneeby gas or fumes 13 leg 13 legAssociated Risk --- Evaluation of 13 electric shock 14 ankle 14 anklePotential If NOT CORRECTED 14 other (provide details below) 15 foot 15 foot1 Loss Severity Potential 16 toes 16 toesa Major 17 shoulder 17 shoulderb Serious 18 arm 18 armc Minor 19 elbow 19 elbow2 Frequency of Exposure 20 forearm 20 forearma High 21 wrist 21 wristb Moderate 22 hand 22 handc Rare 23 fingers 23 fingers3 Probability of Occurrence 24 thumb 24 thumba Extensive 25 non-localized internal 25 non-localized internalb Moderate 26 not specified 26 not specifiedc LowReport Prepared By:Centre for EHS ManagementFile: UEHS_FM_001_2008.xls

Ryerson University AIE Internal Report Page 2 of 4FOR SUPERVISOR TO FILL OUT OR THEIR DESIGNATEDESCRIBE HOW THE EVENT OCCURREDDescribe the sequence of events leading up to the incident,WHERE the incident occurred, WHAT theperson was doing at the time, and the SIZE, TYPE and WEIGHT of equipment or materials involved:KEEP IN MIND THE FOLLOWING CONTRIBUTING FACTORS:People Equipment Materials Environment ProcessIMMEDIATE CAUSES:What Substandard Acts/Practices and Conditions caused orcould have caused the event? Please use checklist on Page 4 and explain here.BASIC CAUSES:What Specific Personal or Job/System Factors caused or could have caused this event?Please use checklist on Page 4 and explain here.Centre for EHS ManagementFile: UEHS_FM_001_2008.xls

Ryerson University AIE Internal Report Page 3 of 4OUTLINE WHAT ACTIONS HAVE BEEN DONE AND SHOULDBE DONE TO PREVENT SIMILAR ACCIDENTSACTIONS TO PREVENT INCIDENT RECURRENCE(check those actions taken to prevent recurrence, mark with a "P" other corrective actions decided upon but no yet taken):Administration Personal Protective EquipmentLeadership Training Health and Hygiene ControlPlanned Inspections and MaintenanceTask Analysis and ProceduresSystem EvalulationEngineering and ChangeAccident/Incident Procedures Personal CommunicationsTask Observation Group CommunicationsEmergency Preparedness General PromotionRules and Work Permits Hiring and PlacementAccident/Incident Analysis Materials and Services ManagementKnowledge and Skill TrainingOff-the-Job SafetySupervisor Comments:LIST SPECIFIC ACTIONS TAKEN BY YOU as the Supervisor. PROVIDE any additionalinformation that may help with the PREVENTION OF AN ACCIDENT of the same or similar natureSupervisor's SignatureDATE: (day/month/year)C h e c k l i s t: (REVIEW AND MARK)Reviewed by Supervisor (Principal Investigator / Coordinator / Manager / Chair / Director / Dean)Recommendations MadeActions TakenWSIB Employer's Report Form 7 filled out (for employees only) and ORIGINAL sent to HR -- copy kept in department fileOriginal Internal AIE Report sent to CEHSMCopy of Internal AIE Report provided to employeeCopy of Internal AIE Report made for Department FileCopy of Internal AIE Report provided to appropriate LOCAL UNION OFFICE at RyersonIF THERE IS AN INJURY OR MEDICAL ATTENTION IS PROVIDED as per s.52(1) OHSADEPARTMENTAL SAFETY OFFICER (DSO) COMMENTS:DSO's NAME:DATE REVIEWED:Centre for EHS ManagementFile: UEHS_FM_001_2008.xls

Ryerson University - CEHSM AIE Internal Report Page 4 of 4IMMEDIATE CAUSES: CHECK ALL APPLICABLESUBSTANDARD ACTS/PRACTICESAn Unsafe Act or Practice is a violation ofa known or accepted safe procedure whichcould permit the occurrence of an accident.SUBSTANDARD CONDITIONSAn Unsafe Condition is a hazardous physicalcondition or circumstance which could directlypermit the occurrence of an accident.Operating equipment without authority Inadequate guards or barriersFailure to warn Inadequate or improper protective equipmentFailure to secure Defective tools, equipment or materialsOperating at improper speed Congestion or restricted actionFailure to follow procedures Inadequate warning systemRemoving or making safety devices inoperable Fire and explosion hazardsUsing defective equipment Poor housekeeping; disorderUsing equipment improperly Hazardous environmental conditions; gases, dusts, smokes, fumes, vapoursFailing to use personal protective equipment properly Noise exposuresImproper loading Radiation exposuresImproper placement Temperature Extremes (High or low temperature exposures)Improper lifting Inadequate or excess illuminationImproper position for task Inadequate ventilationServicing equipment in operationHorseplayUnder the influence of alcohol and/or other drugsBASIC CAUSES: CHECK ALL APPLICABLEPERSONAL FACTORSJOB/SYSTEM FACTORSInadequate Physical/Physiological Capability (Doctor's Opinion) Inadequate leadership and/or supervisionInadequate Mental/Psychological Capability (Doctor's Opinion) Inadequate engineeringPhysical or Physiological Stress Inadequate purchasingMental or Physiological Stress Inadequate maintenanceLack of Knowledge Inadequate tools/equipmentLack of Skill Inadequate work standardsImproper Motivation Excessive Wear and tearAbuse or misuseREVIEWER'S REACTIONS TO THE INVESTIGATOR'S ANALYSIS OF THE BASIC CAUSESOF THIS ACCIDENT AND THE REMEDIAL ACTIONS DIRECTED AT POSSIBLEINADEQUACIES IN THE SYSTEM, ITS STANDARDS OR COMPLIANCE TO THE STANDARDS.Note: In most cases the Reviewer should be at the level of aPrincipal Investigator / Coordinator / Manager / Chair / Director / Dean.Note: The Investigator will be the Supervisor of the person who was involved in the accident/incidentName of Reviewer / Signature / Title / DateCentre for EHS ManagementFile: UEHS_FM_001_2008.xls