Location: Bowdoin / Facilities / Environmental Health and Safety / Accident/Incident Report

Accident/Incident Report

Reporting Guidelines:

  • Employee must report to the attending supervisor immediately and provide a signed statement for the A/I report (separate form*).
  • Witnesses must also provide a signed statement for inclusion in the report.
  • Supervisor will conduct the preliminary investigation as outlined below, and report accordingly:
    • If an emergency, notify Security (x3500) immediately for response services.
    • If situation requires formal investigation and/or hazard elimination; OR if medical treatment beyond basic first aid is needed; OR if lost time is anticipated, first notify Human Resources (x3837) and then the EHS Manager (x3763) immediately.
    • File the written accident/incident report first with HR within 24-hours regardless and a copy to EHS for remediation.
    • If the accident/incident involved chemical exposure, a copy of the MSDS sheet must be attached to the report.

Important Filing Instructions: Required fields are marked with an asterix (*). After completing this form, you will receive an email confirmation. You must print the email confirmation and all parties must sign that copy. The supervisor should retain the signed copy in their file.


Contact Information

Employee's Name:*
 Email:*
@bowdoin.edu		 Extension:*
Supervisor's Name*
 Email:*
@bowdoin.edu		 Extension:*
Department*
Witness(es)
Other Employer(s)

Description of Accident/Incident

Incident Date* Time: AM    PM
Shift Assignment Shift Time: AM    PM
Exact Location*
Description*

Response to Accident/Incident

First Aid Given? Yes    No First Aid Provider:
Medical Treatment Needed? Yes    No Medical Treatment Provider:
Lost Time Anticipated? Yes    No
If yes,
Start Date: 		Start Time: AM    PM
Security or EHS/HR Notification? Yes    No
If yes,
Call Date: 		Call Time: AM    PM
Specific response actions taken

Prevention

Safety device available? Yes    No
Safety device in use? Yes    No
Safety device in use correctly? Yes    No
Describe the safety appliance:
Was a job safety analysis or work activity plan performed for the job? Yes    No
Explain and attach a copy (if Yes):
What has supervision initiated to prevent
this accident from recurring?
Has this accident been discussed with employees and corrective action communicated? Yes    No
How? (if Yes)
Special comment area for corrective action
taken to prevent recurrence of accident:

To submit this report click on the submit button :