Environmental Health and Safety
Injury and Illness Prevention Program
Accident, Injury and Illness Investigation Form
This form should be used to report the results of all investigations of occupational health and safety accidents, injuries, illnesses, near misses, etc. conducted pursuant to the “Accident Reporting and Investigation” section of the SDSU Injury and Illness Prevention Program. Use Continuation Sheet if additional space is required.
| Person(s) Conducting Investigation (Include Title and Department): |
| _________________________________________________________________________________ |
| _________________________________________________________________________________ |
| _________________________________________________________________________________ |
| Date and Time of Accident/Injury/Illness: ________________________________________________ |
| Names/Positions of Affected Employees: |
| _________________________________________________________________________________ |
| _________________________________________________________________________________ |
| _________________________________________________________________________________ |
| Location Where Accident/Injury/Illness Occurred: __________________________________________ |
| _________________________________________________________________________________ |
| Description of Accident/Injury/Illness: ___________________________________________________ |
| _________________________________________________________________________________ |
| _________________________________________________________________________________ |
| What Workplace Condition, Practice or Protective Equipment Contributed to the Incident? |
| _________________________________________________________________________________ |
| _________________________________________________________________________________ |
| Was a Code of Safe Practice or Written Operating Procedure Violated? Yes _____ No ____ |
| If So, Describe: ____________________________________________________________________ |
| _________________________________________________________________________________ |
| Are Changes to Written Safe Practices or Operating Procedures Needed? Yes ____ No ____ |
| If So, Describe: ____________________________________________________________________ |
| _________________________________________________________________________________ |
| _________________________________________________________________________________ |
| Was the Unsafe Condition or Practice (If Any) Corrected Immediately? Yes _____ No ____ |
| If No, What Actions Have Been Taken to Prevent Recurrence in the Interim? ____________________ |
| _________________________________________________________________________________ |
| _________________________________________________________________________________ |
| _________________________________________________________________________________ |
| What Other Corrective Actions Are Needed to Prevent Recurrence? |
| _________________________________________________________________________________ |
| _________________________________________________________________________________ |
| _________________________________________________________________________________ |
| Should Inspection Procedures or Frequency for the Area Be Modified? Yes _____ No _____ |
| If So, What Changes Should Be Made? __________________________________________________ |
| _________________________________________________________________________________ |
| _________________________________________________________________________________ |
| Name of Person Preparing Report: _____________________________________________________ |
| Signature: ________________________________________ Date: ___________________________ |
Distribution Instructions
Submit Completed Original Form to Environmental Health and Safety
At a Minimum, Submit Copies to Following:
The Center for Human Resources (Attn: Benefits Manager)
Chair or Director of Department(s) of Affected Employees
Chair or Director of Department(s) Responsible for Corrective Action
Use Continuation Sheet to describe items of non-compliance and identify corrective actions to be taken.
This page last updated March 7, 2008
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