Iif incident and injury free activities hsse jgc holdings. The type of report form to be used for this case is an accident report form which will indicate the details of the occurrence. Actual event incident a situation that did occur either with or without harm or injury to the individuals. Incident and injury free programme has been introduced and implemented in. Safety breakthroughs jmj associates safety consultant. When completing an incident report form, one must always remember to include important details, including the reporters name, contact details, and address.
Instructions for the incidentaccident investigation form. The incident use additional paper as needed, reference below and attach describe what happened. Incident information property damage incident date. Security guard incident report pdf fill out and sign. Free workplace accident report templates smartsheet. Complete this form as soon as possible after an incident that results in serious injury or illness. The injured employee should fill out this prebuilt employee incidentaccident report it also includes a back injury report, if applicable. Incident and injuryfree approach is no one getting hurt, it differs signi. In case an incident occurs in the health care or medical facilities such as a hospital or a nursing home, an incident report is required. An unexpected incident or exposure that results in an injury or illness to an employee or property damage.
Executive commitment presented by clinton safety man gray i care about safety because i think it is a direct, tangible way to connect with human beings on a nondebatable goal that is truly important to every human being. It is about each worker going home healthy every day and working in an environment where they are safe and treated with dignity and respect. A report form is a form where specific pieces of evidence and issues are being stated. Incident and injury free is not so much about numbers as it is a new mindset about safety. The document may become a legal accounting of the facts surrounding the incidentaccident. Incident report form free download printable templates lab. Incident and injury free iif behavioural safety programme may 2011 phase 3, the programme was customised and became laing orourkespecific. Employees report of injury form university of iowa. Abstract in the oil and gas industry, in the last decade the incident. You may specify an estimated date if you happen to forget the exact day of the occurrence. We help teams believe that incident and injuryfree performance is possible, are committed to that result and enroll others in this possibility.
Incident and injuryfree is not so much about numbers as it is a new mindset about safety. In case an incident occurs in the health care or medical facilities such as a hospital or. I understand the information above will be used by my employer to help determine liability for the injury. Child care injury incident report child care program. Incident and injuryfree iif safety approach explained. Name of injured child age of child childs gender male female date of incident time of incident am pm called 911 called poison control check all that apply type of injury incident open wound cut dislocation sprainstraintwist burn. Check at least one church official listed who has been notified of incident. Name of injured child age of child childs gender male female date of incident time of incident am pm called 911 called poison control check all that apply type of injury incident open wound cut. Incident and injury free incident and injury free is about creating a workplace committed to eliminating worker injury. Incident reporting and investigation form 101210, page 1of 3. Actual eventincident a situation that did occur either with or without harm or injury to the individuals. Safety breakthroughs jmj associates safety consultant company.
An incident and injuryfree commitment is to the elimination of all incidents, injuries and deaths, no kidding. Published papers deal with medical, legal, economic, educational, behavioral, theoretical or empirical aspects of. May consider 24 hours, 3 days but should be no more than 5 days. Its a way of thinking that avoids incidents and injuries, making safety a high priority on both a personal and organizational level. The incident and injury free iif program is based on the idea of workers watching out for each other and ensuring that everyone involved in a construction. The article summarizes the creation of the approach, its evolution and what it means that iif safety is an integral approach. One must then state the date in which the incident occurred, along with the location and time of when it took place. Incident and injury free programme has been introduced and implemented in pearl gtl project in qatar. Feb 25, 2010 the jmj incident and injuryfree approach is dynamicsuited to entire organizations or individual projects and tailored to meet the speci. This injury and illness incident report is one of the first forms you must fill out when a recordable workrelated injury or illness has occurred.
The programme is working very well and, at the same time, it is also been observed that its effectiveness depends on how to implement the programme. At the core of the incident and injury free approach is an organizational culture totally committed to the elimination of workplace. Determined by your company and state workers compensation program policy. Developed by jmj associates of austin texas, the iif system requires a change in safety attitudes from simple compliance with rules and regulations to a mindset that intends to eliminate work related incidents and injuries all together. We draft recommended practices, promote the integration of safety into every aspect of daily operations, work to develop a level playing field for safety across the industry, and collect the safety data that direct our activities. The incident and injuryfree iif safety management approach. The planning for iif orientations for the dredge crews was begun, the safety leadership team slt was formed, volunteers for train the trainer were selected and managers, captains. Its a way of thinking that avoids incidents and injuries, making. The jmj incident and injuryfree approach is dynamicsuited to entire organizations or individual projects and tailored to meet the speci.
We help teams believe that incident and injury free performance is possible, are committed to that result and enroll others in this possibility. There are a lot of uses of report forms and one of them is for those who witnessed an accident. This form will be submitted to the mtf patient safety manager, risk manager, or other responsible individual iaw local policy, nlt 48 hours after the event. State the operations and treatments to be administered. This incident form template can typically be used to document an auto accident, but it can also be used for other types of injury accidents. The incident reporting form is a report that records the detailed information of an incident such as when, where and why it occurs. Iif incident and injury free implementation in the workplace. Building an incidentfree safety culture safety policy. Write the injured individuals full name and a few personal details. Jmjs incident and injuryfree iif safety approach was featured in the petroleum institute of thailands ptit focus. Fill, sign and download injury report form online on. Incident and injury report form details of incident e. Death lost time erclinic treatment first aid only near miss. Start a free trial now to save yourself time and money.
Free injury incident report form template pdf word doc. At the core of the incident and injuryfree approach is an organizational culture totally committed to the elimination of workplace. I acknowledge that the above statement is a true and accurate representation of this information. Developing skills we help build team capabilities in thinking, conversing and performing their daily work initiatives that foster an incident and injuryfree performance. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds.
Occasionally, someone who reports an employee incident report template does not remember the specific details of the event. The purpose of an incident management policy is to ensure that all incidents that can affect an organizations daily operations are managed using an established process. Often referred to as a near miss, this is an event that could have resulted in personal harm or property damage. Therefore the incident and injury free iif process is a process that focuses on the current safety program, improves performance and addresses what is missing. The reporter must then describe details of the incident, such as the. It is not a commitment to improvement or doing better than last year.
Developing skills we help build team capabilities in thinking, conversing and performing their daily work initiatives that foster an incident and injury free performance. Incident report form use this form to report accidents, injuries, medical situations, or student behavior incidents. Together with the log of workrelated injuries and illnesses and the accompanying summary, these forms help the employer and osha develop a picture of the extent and severity of workrelated incidents. Oshas form 301 injuries and illnesses incident report.
Incident and injuryfree is about creating a workplace committed to eliminating worker injury. Describe who was involved, when and where the incident happened, what happened, and how. Download incident report template for free formtemplate. In 2004 kieron deeney died on a laing orourke site in canary wharf when he fell through an inadequately protected hole in an apparently safelooking concrete floor. An incident report, also called the accident report which is used to keep the record of the unfortunate incident.
Incident and injuryfree incident and injuryfree is about creating a workplace committed to eliminating worker injury. Incidents involving a crime or traffic incident should be reported directly to the campus public safety office. Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness. M nature of incident near miss first aid medical treatmentdoctor name of injured person mary smith activity in which person was engaged at the time of the incidentinjury mary smith was checking her phone while walking. Iogp for an incident and injury free oil and gas industry.
Free injury incident report form template pdf word. Fill out, securely sign, print or email your security guard incident report pdf form instantly with signnow. Parsing the meaning and means of one of the ehs fields highest goals, we find senior leaders can overcome the cultural pessimism that impedes success. It is essential for people to create the incident report form to avoid the unfortunate incident. Iif is a process of realignment of a companys safety culture. Employee incident report pdf charlotte clergy coalition. Write the date, exact time and location of the incident. Incident and injury free approach is no one getting hurt, it differs signi. Changing the culture to achieve incident and injury free iploca. Use this template to collect the injured employees personal information and the circumstances of the accident, including the duties the employee was performing at the time of the event, the objects or machinery involved, the severity of the injury the.
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