Safety Committee

Occupational Injury/Ilness Investigation Report


Employee Name 
Department
File Number
Contact Date

EMPLOYEE STATEMENT/WHAT OCCURRED:

Witnesses? Yes No

Interviewed? Yes No (If yes, please explain)

Action Taken By Investigator: (Counseling, training, repair, PPE, etc.)

 

Investigator:


When  completed, return form to the EHRS Department, Box #85.

University of the Sciences in Philadelphia • 600 South Forty-third Street • Philadelphia, PA 19104-4495 • phone: 215-596-8800 • email: safety@usip.edu