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Security Incident Report Form Page 2
Incident Report Template 2
SUPERVISOR’S INVESTIGATION OF CAUSE (CHECK ONE OR MORE)
If employee admitted to hospital, OSHA must also be contacted within 24 hours. This is a supervisor’s
responsibility – Call OSAH at 776-6030.
Did you personally view the incident site Yes No Employee Category Faculty Staff Student
UNSAFE ACTS UNSAFE CONDITIONS
OPERATING WITHOUT
AUTHORITY
HORSEPLAY IMPROPERLY GUARDED
EQUIPMENT OR MACHINE
INADEQUATE WARNING
SYSTEM
FAILURE TO WARN OTHERS FAILURE TO USE PERSONAL
PROTECTIVE DEVICES
DEFECTIVE TOOL OR
EQUIPMENT
HAZARDOUS STORAGE OR
ARRANGEMENT
OPERATING OR WORKING AT
UNSAFE SPEED
FAILURE OT OBSERVE SAFETY
REGULATIONS
POOR HOUSEKEEPING HAZARDOUS DRESS OR
APPAREL
MAKING SAFETY DEVICES
INOPERATIVE
LACK OF TRAINING OR
KNOWLEDGE
IMPROPER LIGHTING HAZARDOUS WORK
PROCEDURE
FAILURE TO SECURE OBJECTS PREVENTABLE VEHICLE
ACCIDENT
IMPROPER VENTILATION (DUST,
FUMES, ETC.)
HAZARDOUES WEATHER OR
ENVIRONMENT
USING UNSAFE EQUIPMENT OR
EQUIPMENT UNSAFELY
SLIPS AND FALLS UNSAFE DESIGN OR
CONSTRUCTION
CONTACT WITH POISONOUS
PLANTS, INSECTS, TOXIC
UNSAFE LOADING, MIXING,
CARRYING
FAILURE TO LOCK OUT/TAG
OUT
SLIPPERY OR OTHER UNSAFE
SURFACE
CHEMICALS, SKIN IRRITANTS,
BITES, ECT.
TAKING UNSAFE POSITION OR
POSTURE
OTHER:
_________________________________
OTHER:
_________________________________
REASONS FOR UNSAFE ACT (Must be completed by Supervisor)
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
REASONS FOR UNSAFE CONDITION (Must be completed by Supervisor)
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
WHAT PRACTICAL CORRECTIVE ACTION WILL BE TAKEN BY SUPERVISION TO PREVENT RECURRENCE (Must be
completed by Supervisor.) Note: The wording “be more careful” is unacceptable, as it does not present a viable solution. If the cause is
properly identified, there should be several solutions.
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
SUPERVISOR’S SIGNATURE _______________________________________________ DATE ___________________________
MANAGEMENT REVIEW SIGNATURE ______________________________________ DATE ___________________________
 CHECK IS SAIF FORM 801 WAS COMPLETED. (801 MUST BE COMPLETED AND RECEIVED BY THE SAIF
COORDINATOR WITHIN 24 HOURS)
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