ENSATS Injury/Illness/NearMiss/Incident Reporting Form
Near Miss - An unplanned event that did not result in injury or damage but had the potential to Incident - An unplanned event that disrupts work or causes damage but no injury occurs Injury/Illness - an unplanned event that causes harm to a person All incidents & injuries should be reported verbally as soon as reasonably possible to HR, Safety & employees direct supervisor. Documentation of all reports should be completed within 24 hours of event. This form should be used only to report workplace incidents that occurred either on campus or while completing work related duties off site during a shift.
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Employee Details
Name & job title of the employee involved in incident/injury/near miss
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List direct supervisor
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Have you notified your direct supervisor of this event
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Please Select
Yes
No
Date of incident/injury/near miss
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Month
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Day
Year
Date
Time of incident/injury/near miss
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Hour Minutes
AM
PM
AM/PM Option
Witnesses (leave blank if none)
Department & Location where event occurred
Select type of event that occurred
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Please Select
Near Miss
Incident
Injury/Illness
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Near Miss
An event that had the potential to cause injury, illness or damage
Describe the Near Miss event in full detail
List all equipment, machinery, materials, or chemicals employee was using when event occured
Identify factors you believe contributed to the event
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Incident
An unplanned event that disrupts work or causes damage but no injury occurs
Describe the full incident in detail
List all equipment, machinery, materials, or chemicals employee was using when event occurred
List factors you believe contributed to the event
Were proper procedures being followed when the incident occurred? (Yes, No - If no explain)
Was the employee wearing proper PPE (Personal protective equipment) (Yes, No - If no explain)
Are changes in equipment necessary to prevent reoccurrence? (Yes, No - If Yes explain)
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Injury/Illness
An unplanned event that cause harm to a person
Describe nature of the injury or illness (Strain, cut, fall etc)
Body Part(s) affected:
Describe the events leading to the injury/illness in detail
List all equipment, machinery, materials or chemicals the employee was using when the injury occurred:
Identify the factors that you believe contributed to or cause the injury
Was medical treatment required beyond first aid? (Yes/No - If yes please define)
Name of facility, urgent care, hospital, or physician for treatment (If applicable)
Was the employee hospitalized over night as a patient?
Please Select
Yes
No
Not Applicable
Was the employee provided any work restrictions? (Yes/No - if Yes, what?)
Date employee returned to regular duty
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Month
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Day
Year
Date
Date employee returned with light duty restrictions (if applicable)
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Month
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Day
Year
Date
Were proper procedures being followed when the incident occurred? (Yes/No - If no explain)
Was the employee wearing proper PPE (Personal protective equipment) (Yes, No - If no explain)
Are changes in equipment necessary to prevent reoccurrence? (Yes, No - If Yes explain)
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I certify that the information listed in this form is accurate and I have notified my direct supervisor of the submission
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