ࡱ> >@=] bjbjzz . 1\1\(((( 4(HHHHH###$G> ##  >HHS HH HYo G6Fi0|(,#Z}@4/###>>4###    #########> :  ɫ, Pomona  Environmental Health & Safety STUDENT ACCIDENT INJURY AND ILLNESS INVESTIGATION FORM This form is to be utilized to document the investigation of an accident, injury, or near miss incident. ____________________________________________________ ________________________________________________ Person(s) Conducting Investigation Title(s) ____________________________________________________ ________________________________________________ Date of Accident/Injury/Illness Name(s) of Affected Student(s) ____________________________________________________ ________________________________________________ Instructional Class/Activity of Affected Student(s) Part(s) of Body Affected Nature of Accident/Injury/Illness:________________________________________________________________________________ ___________________________________________________________________________________________________________ What Workplace Condition, Work Practice or Protective Equipment Contributed to the Incident? _____________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________ Was a Mandatory Safe Work Practice violated? ____________________________________________________________________ Witness Names and Statements: ________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What Corrective Actions Will Prevent Another Occurrence? __________________________________________________________ ___________________________________________________________________________________________________________ What Additional Mandatory Safe Work Practice will be Needed? _________________________________________________________ ___________________________________________________________________________________________________________ Was the Unsafe Condition, Practice or Protective Equipment Problem Corrected Immediately? (Circle one of the following) Yes No If No, What Has Been Done to Ensure Correction __________________________________________________________________ ___________________________________________________________________________________________________________ Until Corrected, What Actions Have Been Taken to Prevent Recurrence in the Interim? _________________________________________ ___________________________________________________________________________________________________________ What Modification of the Area Inspection Checklist Is Needed to Prevent Recurrence of the Problem? _________________________ ___________________________________________________________________________________________________________ _________________________________________________ _____________________________________________________ Signature of Investigator Date _________________________________________________ _____________________________________________________ Signature of Person Responsible for Corrective Actions Date Copy of This Report was Received by Responsible Party (Principal Investigator/Department Chair) (Principal Investigator/Department Chair) _________________________________________________ Print Name Distribution: White/Department Responsible for Corrective Action - Green/Individual Conducting Investigation Canary/Department Conducting Inspection - Pink/Environmental Health & Safety Revised: 09/29/2003 +[ ] ~hs[h O h o5jhr#U h oEHh ojhr#UI J - . 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GalindoOh+'0,8`l       ɫ, Pomona  Environmental Health & Safety Normal.dotmJulie Anne M. Galindo11Microsoft Office Word@Z@c+@(u@m GB՜.+,0 hp  n Environmental Health & Safety  ɫ, Pomona Title  !"#$%&'()*+,./012346789:;<?Root Entry F [ho GAData |1TableWordDocument. SummaryInformation(-DocumentSummaryInformation85CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q