Office of Research Safety
Laboratory Safety Manual
210 Accident Investigations
1. Purpose
1. To establish a reporting procedure that will ensure compliance with OSHA Recordkeeping
requirements and identify factors that must be controlled to eliminate occurrences.
2. Scope
1. This procedure applies to all faculty and staff using laboratories in Biology, Chemistry, Liquid
Crystal Institute, Physics, Psychology, Anthropology, Exercise, Leisure and Sport, Technology,
and Geology Departments and all studios in the School of Art.
3. References
1. Employee Report of Injury or Occupational Illness Form. Office of Risk Management
http://www.kent.edu/ceo/Safety/upload/Injury%20Report.pdf
2. Non-Employee Report of Injury or Illness Form
http://www.kent.edu/ceo/Safety/upload/NonEmpIncident.pdf
4. Responsibilities
1. Employees and non-employees (i.e. students, visitors) must report all work related incidents that
resulted in injuries, illness or property loss to their immediate supervisor. Incidents of the near
miss kind that did not result in any loss should also be reported.
2. Supervisors will ensure that the employee completes the Employee Report of Injury or
Occupational Illness, complete their copy of the Supervisor’s Statement and distribute the
completed forms. Supervisors will complete the non-employee report form
3. Department Chemical Hygiene Officer or Department Safety Officer will assist in the completion
of the forms and ensure proper distribution.
4. Manger, Laboratory Safety will follow up with a systems investigation and make
recommendations to CHARM, Department Heads or DCHO as appropriate to prevent future
recurrence of the incident.
5. Procedures
1. The first concern whenever an incident has occurred is to attend to the injured person (s) and
minimize damage to equipment and buildings.
2. After the injured have been taken care of and the emergency has been controlled, or upon being
told of an incident, the employee’s immediate supervisor will obtain the Employee Report of
Injury or Occupational Illness or Non-employee Report of Injury or Illness. See link to form in
section 3 above. See pages 3 &4 for an example of the form. Do not use this copy of the form to
make the report; reports must only be made on the original form.
3. The Supervisor will report incident to the DCHO or Department Safety officer and will ensure
completion of the form by following the instructions provided. See pages 5-7 for a copy of
“Instructions for Completion of the Report of Employee Injury or Illness”.
4. After the forms have been completed, send one copy to the Manager, Laboratory Safety, one copy
to the Department Chemical Hygiene Officer or Safety Officer, and send the white and yellow
copies of the Accident Report and Supervisor’s Statement to the Office of Risk Management.
Case No. __________________
EMPLOYEE REPORT
OF INJURY OR OCCUPATIONAL ILLNESS
Employee Identification
1. Name
( To be completed by Safety Officer)
2. Home Address
3. Home Phone
4. Department
7. S.S. No.
8. Birth Date
5. Work Phone
9. Sex
6. Length of KSU
Employment
11. on University Property? Yes o No o
on University Business? Yes o No o
10. Job Title
Part 1 – Injury or Illness Information (To be completed by Employee)
12. Date of incident: __________________
13. Time: _________ A.M or P.M.
14. Date & Time reported to Supervisor:______________________________________
15. Description of events leading to injury – where were you, what were you doing, cause of injury, etc. (Be specific): ______________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
16. Witnesses: No o
Yes o ; if yes:
(1) _______________________________________________________________________________
Name
Place
Dept. Phone
an (X) on
(2) _______________________________________________________________________________
Name
Injured
Dept. Phone
Area(s)
17. Part of Body Injured
Left Right
o
o
o
o
o
o
o
o
o
o
Left Right
o
o
o
o
o
Hand
Thumb
Finger(s)
Wrist
Arm
o
o
o
o
o
Elbow
Shoulder
Thigh
Knee
Calf
Left
o
o
o
o
o
Right
o
o
o
o
o
Ankle
Foot
Toe(s)
Eye
Ear
o
o
o
o
o
o
o
o
o
Face/Teeth
Head
Abdomen
Back Lower
Back Mid
Back Upper
Groin
Neck (cervical)
Nose/Throat/Lungs
18. Nature of Injury
o
o
o
o
o
o
Laceration
Puncture
Insect/Animal Bite
Burn
Abrasion
Contusion
o
o
o
o
o
o
Sprain
o Other – Show in Remarks _______________________________________________
Strain
Fracture/Dislocation _____________________________________________________________________
Inhalation
Foreign Matter
______________________________________________________________________
Skin Irritation
In Case of Back Strain, Abdominal Regions, or Hernia, Answer Items 19 through 22:
19. Approximate weight of object handled _________How high was it lifted? _________
Was this kind of work performed regularly?
o Yes
o No
20. Were you subject to unusual strain or circumstances? _________ No ________ Yes; if yes, explain: _________________________________________________________
______________________________________________________________________________________________________________________________________________
21. Did injury appear immediately? ______________ Yes __________ No; if no, explain: ___________________________________________________________________
______________________________________________________________________________________________________________________________________________
22. Did you slip, fall, or strike yourself? _____________ No ____________ Yes; if yes, explain: ______________________________________________________________
______________________________________________________________________________________________________________________________________________
Was first aid given? o Yes o No
Did you go to the Doctor? o Yes o No
______________________________________________
Did you go to hospital? o Urgent Care o University Health Care o
If hospital/care facility, please give name and address:
________________________________________________________
Have you filed for Workers' Compensation before?
o Yes o No; if yes,where:___________________________________________
_________________________________________________________________
Nature of previous claims____________________________________________
_________________________________________________________________
Is this injury a recurrence or aggravation of an old injury? o Yes o No
I, the injured employee, herein certify that the information set forth above is true and correct to the best of my knowledge.
1 Original - Personnel
1 Copy - Environmental Health Office
1 Copy - Department
______________________________________________________________
Employee’s Signature
Date Signed
Part II – Statement of Supervisor (To be completed as an INDEPENDENT report from Employee’s Report)
Employee Name: ______________________________________________________________________
I personally witnessed this accident: o Yes
o No
Date of Injury: __________________________________________
List exact nature of injury and apparent cause of accident: ________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
Answer the following questions in relation to the cause of the accident. Answer only those questions which you feel completely qualified to answer.
1. Was the employee using approved methods in performing a duty at the time of the injury? o Yes o No
2. Was the employee required to wear safety equipment? o Yes o No Was the employee using safety equipment? o Yes o No
3. If mechanical equipment was involved, was the employee trained in use of equipment and/or procedures related to job functions? o Yes o No
4. Was the equipment faulty? o Yes o No
6. Was any immediate corrective action taken? o No o
5. Did the employee commit an unsafe act? o Yes o No
Yes; if yes, what? ____________________________________________________________________________
State any inconsistencies you found while investigating employee’s statements:_______________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
o
I have investigated this incident and agree that the injury did occur while the employee was on duty and as he/she described above.
o
I feel further investigation of this incident is required.
_________________________________
Date Injury Reported to Supervisor
____________________________________________________________________________
Supervisor’s Signature
_________________________________
Date Report Completed
Part III – Statement of Witness (if applicable)
Name of Witness:
I Personally Witnessed The Incident Involving: (Name of Injured Employee)
I believe that a true description of the incident is the following:
(Signature)
(Date)
Name of Witness:
I Personally Witnessed The Incident Involving: (Name of Injured Employee)
I believe that a true description of the incident is the following:
(Signature)
1 Original - Personnel
1 Copy - Environmental Health Office
1 Copy - Department
(Date)
Revised 08/03/05
NONEMPLOYEE INCIDENT REPORT
Person(s) involved: (Repeat this section as needed on the back of this form.)
NAME
___________________________________________________
ADDRESS
___________________________________________________
___________________________________________________
PHONE
(_____) ___________________________________________
Incident Date
Location
___
Time
AM __ PM __
_________________________________________________________________
Affiliation with University:
Student __
Full Description of Incident:
Visitor __
______________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Witness(es):
Name
__________________________________________________
Address
__________________________________________________
Phone
(____)____________________________________________
Name
__________________________________________________
Address
__________________________________________________
Phone
(____)____________________________________________
Medical Treatment?
YES __
NO __
If yes, transported for treatment by whom? ____________________________
Where was individual transported? _____________________________________
Diagnosis and type of treatment? _____________________________________
_______________________________________________________________________
Report completed by:
____________________________________________________
Title:
Date Reported:_________________
Send copies within 24 hours to:
James Watson, University Counsel
Dave Young, Treasury, Tax, & Risk Management Svcs.
James Dunlap, Occupational Health & Safety
Occupational Health and Safety
Campus Environment & Operations * Kent, Ohio 44242-0001
Phone: (330)672-9565 * Fax: (330)672-9561