Incident Investigation Form

This form must be completed and returned to Human Resources within 2 working days of the work or study related injury or illness of an employee, student, or guest.

Note to person completing this form: An accident investigation is not designed to find fault or blame. It is an analysis to determine causes that can be controlled or eliminated.

Once submitted, this form will be routed electronically to (1) the University Laboratory Safety Coordinator or Director of Environmental Health and Safety, as appropriate, (2) the Office of Human Resources, and (3) the Office of General Counsel. The University Laboratory Safety Coordinator or Director of Environmental Health and Safety will route it to the head of the appropriate department.

I. Incident Information
  • Date injury occurred*:
  • Time of injury*:
  • Shift:
  • Department/Location*:
II. Injured Person
  • Name*:
  • A number*(enter "NA" if not applicable):
  • Status*
    • Full Time Employee
    • Part Time Employee
    • Contractor
    • Temporary Employee
    • Student
    • Guest
    • Other
  • Address:
  • Age*:
  • Phone*:
  • Job Title*(enter "student" if you are a student):
  • Supervisor/Associated Faculty member*:
  • Length of Employment at IIT:
  • Length of Employment at Job:
  • Nature of Injury*
    • Bruising
    • Dislocation
    • Strain/Sprain
    • Scratch/Abrasion
    • Internal
    • Fracture
    • Amputation
    • Foreign Body
    • Laceration/Cut
    • Burn/Scald
    • Chemical Reaction
    • Other (Specify):
    • Injured body part:
    • Remarks:
  • Treatment
    • Name and address of treating physician or facility
    • First aid:
    • Emergency room:
    • Medical office visit:
    • Hospitalization:
III. Damaged Property
  • Property, equipment or material damaged:
  • Description of damage:
  • Object or substance causing damage:
  • Describe what happened:
    (Please email photographs or diagrams if necessary to hr@iit.edu)
IV. Root Cause Analysis*
  • Check All That Apply Based on Observable/Known Facts
  • Improper Work Technique
  • Safety Rule Violation
  • Improper PPE or PPE Not Used
  • Inadequate Ventilation/Lighting
  • Improper Material Storage
  • By-Passed Safety Device/Guard
  • Slippery Conditions
  • Improper Lifting
  • Horseplay/Unsafe Act of Other
  • Inadequate Fall Protection
  • Improper Loading/Placement
  • Poor Workstation/Process Design/Layout
  • Congested Work Area
  • Hazardous Substance
  • No PPE
  • Insufficient Worker Training
  • Improper Maintenance/Inspection
  • Improper/Inadequate Tools/Equipment
  • Inadequate Job Planning/Scheduling
  • Poor Housekeeping
  • Drug/Alcohol Use
  • Inadequate Guarding of Hazard
  • No Written Procedure/Policy
  • Safety Rule Not Enforced
  • Operating Without Authority
  • Failure to Warn/Secure Inadequate
  • Operating at Improper Speeds
  • Insufficient Supervisor Training
  • Insufficient Knowledge of Job
  • Inadequate Supervision
  • Excessive Noise
  • Servicing Machine In Motion
  • Unnecessary Haste
  • Unknown
  • Other
V. INCIDENT ANALYSIS
  • Using the Root Cause Analysis list above, explain the cause(s) of the incident in as much detail as possible, focusing on known facts (Please email an extended explanation if needed to hr@iit.edu)*.
  • How Bad Could the Accident Have Been?*
    • Very Serious
    • Serious
    • Minor
    • As Bad
    • As Likely
  • What Is the Chance of the Accident Happening Again?*
    • Very Likely
    • Likely
    • Possible
    • Unlikely
VI. Preventative Actions*
  • Describe actions that will be taken to prevent recurrence*:
  • Deadline*:
  • Responsible Party*:
VII. Investigation Team
  • Name*:
  • Position*:
  • Date*:

  • Name:
  • Position:
  • Date:

  • Name:
  • Position:
  • Date:
VIII. Person Completing this Form
  • Name*:
  • Email address*:
  • Date*:
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