Department: The University of Maine Safety and Environmental Management Department Page 1 of 2 Document: Tier I – Incident Investigation Report MF05012, 05/06/2015

Tier I – Incident / Injury - Investigation Report

Injured Employee Name and Phone Number: Type of Incident: (please check all that apply)

Injury Direct Cause: ______Supervisor Name and Phone Number: Illness

Spill/Gas/Vapor Date of Incident and when it was reported Fire Property Damage - Estimated cost of damage: $ Indoor Environmental Concern Time of Incident: (indicate AM / PM) Other (please describe)

Injury Location: Department:

Instructions: The Tier I report is to be completed by SEM or department representative, and should include input from the supervisor and the employee(s) involved in the incident.

Purpose of this investigation and interview is to do fact-finding, not fault-finding. The purpose of this form is to provide a more detailed description of the incident. A thorough understanding of the task being performed and identification of contributing conditions, will help us to take appropriate corrective actions, thereby reducing risks

Be prepared and have an investigation kit which will include: investigation forms, interview forms, barricade tape, warning tags or padlocks, voice recorder & camera (phones can be used), measuring tape, flashlight and sample baggies.

1. Describe the task(s) being performed when the incident occurred.

* Supervisors Workplace Injury Report Form completed and reviewed prior to Tier I investigation. 2. Provide a detailed description of how the incident occurred. (Sequence of Events)

2.1 What was the employee(s) doing BEFORE the incident occurred?

2.2 Approximately how many times did the employee(s) complete this job task prior to the current incident?

2.3 Was there anything out of the ordinary going on prior to the incident? If so, describe.

2.4 Have employee(s) had a problem with this job task or equipment prior to the incident? If so, describe.

2.5 Can anyone think of any other concerns related to this incident? If so, describe.

2.6 List people interviewed and attached the interview statements. Department: The University of Maine Safety and Environmental Management Department Page 2 of 2 Document: Tier I – Incident Investigation Report MF05012, 05/06/2015 3. The following causal factors have been provided AS A GUIDE to identify potential causes and prevent future occurrences. Review all potential causes and circle yes or no for each item.

3.1 Equipment Yes No 3.2 Individual/Management Performance Yes No Repeat Failure Difficult job task Equipment design issue Rushing or frustration Equipment defective Inattention (eyes/mind not on task) Improper use of equipment Pre-existing injury Inadequate guards/barrier Inadequate PPE Improper position for task Abuse/misuse Inadequate warning systems Inadequate training Inadequate lighting Ergonomic concern Inadequate ventilation SOP incorrectly used Poor housekeeping Lack of communication Other: Other:

4. Recommendations – For each item checked yes, attempt to develop a recommendation that will prevent future occurrences. (Attach additional copies of this page if needed). Final recommendations will be sent to the SEM Department. The record will then be entered into the SEMCAT system.

Recommendations Lead Person Estimated Closed Due Date Date 4.1

4.2

4.3

4.4

4.5

Note: A copy of the SEMCAT report shall be sent to the appropriate management personnel

5. Personnel present at the investigation: Employee Name: Date: Employee Name: Date: Supervisor Name: Date:

Investigator Name (Print) Investigator Name (Signature) Date:

SEM – OFFICE USE ONLY: Initial Report Number If Applicable, OSHA 301 Case Number

Medical Provider(s) Work Restrictions or Lost Days

Attach Photo’s here