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 student and employee incidents or injuries should be reported verbally as soon as reasonably possible to the employee’s direct supervisor and Human Resources. When a student is involved, the student’s caregiver(s) should also be notified as soon as reasonably possible, consistent with District procedures. Documentation of all incidents, injuries, and required notifications should be completed within 24 hours of the event. This form should be used to document incidents or injuries involving students or employees that occur either on campus or while participating in school- or work-related activities off site.
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Employee/Student Details
Name & Job Title/Role of Employee or Student Involved in Incident/Injury/Near Miss
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Name & Job Title of Employee’s Direct Supervisor or Student’s Responsible Staff Member
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What Department/Program are you in?
Have you notified the employee’s direct supervisor or the appropriate staff member responsible for the student regarding this event? (Yes/No)
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Please Select
Yes
No
If applicable, have you notified the student's caregiver regarding this event? (Yes/No)
*
Please Select
Yes
No
N/A
Date of incident/injury/near miss (Must be reported within 24-hours)
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
If applicable, list all equipment, machinery, materials, or chemicals the employee or student was using when the event occurred.
Identify any 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:
If applicable, list all equipment, machinery, materials, or chemicals the employee or student was using when the 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 or student wearing the required Personal Protective Equipment (PPE), if applicable? (Yes/No – If no, please 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
If applicable, list all equipment, machinery, materials, or chemicals the employee or student was using when the event 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 describe.)
Name of facility, urgent care, hospital, or physician for treatment (If applicable)
Was the employee or student admitted to a hospital as an inpatient overnight? (Yes/No)
Please Select
Yes
No
Not Applicable
Was the employee or student provided with any restrictions? (Yes/No – If yes, please describe.)
Date Student/Employee Returned to Regular Activities or Duty
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Student/Employee Returned with Restrictions (if applicable)
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Were proper procedures being followed when the incident occurred? (Yes/No - If no explain)
Was the employee or student 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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