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Incident Investigation


Incident investigations are to be conducted with the objective of determining the cause (fact finding), not for determining blame. All incidents involving personal injury, substantial damage to equipment, or near miss that could have resulted in a serious injury, shall be reported to the department head immediately. The investigation for Type A Incidents will be started that same day. No disciplinary action shall be imposed as a result of providing information in an investigation, except when there is a clear, verifiable evidence of disregard of safety rules/procedures or misrepresentation of facts. When an injury/illness occurs, complete the Standard Injury Report located in the Rensselaer Policies and Procedures Manual and the Incident Investigation Form. Also, complete the Incident Investigation Form for near misses and property losses.


  • Download - Incident Investigation Form
  • Check the box for the type of investigation being conducted (i.e., injury, near miss, illnesses, property loss/damage).
  • Fill in employee’s name, date and time of incident, date and time the incident was reported, the employee’s job classification (e.g., mechanic), a specific description of the location where the incident occurred (i.e., North side of loading dock by Cogswell Hall) , the administrative unit (e.g., Physical Plant), and the name of the employee’s supervisor.
  • Investigation Team Members and Date of Investigation. The team should include a supervisor if possible, and one to four co-workers. If a supervisor is present, he/she should be the team coordinator. If a Type A incident, the Director, EH&S will serve as the team coordinator and additional management or faculty personnel may be assigned to the investigation team
  • A description of the incident (i.e., employee was grinding a burr off piping on chute when grinding wheel broke and flew apart striking employees left forearm. One piece, approximately one-half inch by one inch was imbedded).
  • Fill in the names of all witnesses.
  • Contributing Factors. (Fill in each section that applies. If a section does not apply, write N/A in the section).
    1. Equipment, Material, Personal Protective Equipment, Environmental Conditions. What equipment (hand tools, farm implements, etc.), material (i.e., wheel being used was for a lower RPM grinder), Personal Protective Equipment (i.e., what was or was not being worn), environmental conditions (i.e., weather conditions or time of day).
    2. Training Instructions (was the employee trained, does training need to be modified?)
    3. Human Factors/Ergonomics (was the employee trying to save time, in a hurry, or have a deadline to meet? Did the employee not take the time to get the right tool for the job? Did design of the equipment, tools, or work area contribute to the incident?)
  • Root Cause(s) - Utilizing all the information gathered during this incident, what was the underlying cause of the incident?
  • Preventive Action(s) / Recommendation(s)
    1. Immediate Corrective Actions Taken (list any immediate corrective actions taken to prevent the incident from recurring).
    2. Scheduled action plans with responsible person(s) - list the recommendations that the investigation team believes will correct the situation and prevent the incident from recurring (training, modified rules/procedures, or purchase of the correct tool); a person that is responsible for correcting the situation; and a target date for completion.
  • Distribution: Forward the original to the Director, Environmental Health & Safety. Copies should be forwarded to the Dean or Vice-President of the unit where the incident occurred.
Last modified: March 13, 2008
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