HOW TO COMPLETE THE 
INCIDENT/ACCIDENT REPORT (IR)

The Incident/Accident Report (IR) is a two-part stapled form that contains both the Employee Report (IR-E) and the Supervisor’s Report (IR-S).  The information supplied in these reports will assist the Location’s SHEM Committee to identify opportunities where safety may be improved resulting in a safer and healthier workplace environment.

For Employees (IR-E):
					
Side One
1.	Enter your name, whether you are a federal employee or “other”, name of supervisor, and check the Unit location.
2.	Specify the date and time of the incident/accident.
3.	Specify the location of the incident/accident.
4.	Check the type of incident/accident (may check more than one).
5.	Briefly describe the incident/accident.
6.	Provide information on how the incident/accident could have been avoided.

Side Two
7.	Check the notifications made at the time of the incident/accident (may check more than one).
8.	List any witnesses to the incident/accident (first and last name).
9.	Check the “action” causing the incident (may check more than one).
10.	Check the type of injury.
11.	Check the box that specifies the body area of injury, circle on the diagram and provide brief description of injured area.
12.	Briefly describe any corrective actions taken at the time of the incident/accident.
13.	Sign and date the form and immediately give to your supervisor.
14.	Fax copy (both sides of report) to the Location LAO at 608/890-0048.

For Supervisors (IR-S):

Side One
1.	Enter your name and check the unit location.
2.	Review the IR-E report submitted by the employee.
3.	Answer the 7 questions in the “Incident/Accident Report Supervisor Verification” section.
4.	Answer the “Supervisor Analysis” question.

Side Two
5.	Answer the 6 questions in the “Actions Taken to Avoid Repeat Occurrence” section.
6.	Sign and date the form and return both copies to the:
												
		USDA-ARS-MWA-Madison
		Administrative Office 
		1925 Linden Drive
		Madison, WI  53706

USDA-ARS-MWA-Madison		  INCIDENT/ACCIDENT REPORT (IR-E-2006)
	
Specify Unit Location:
~   CCRU - 502 N. Walnut Street			TO BE COMPLETED BY INCIDENT REPORTER:
~   CCRU - Russell Labs - 1630 Linden Drive			
~   DFRC - 1925 Linden Drive	
~   DFRC Farm - S8822 State Rd Hwy 78, PDS 	~ Federal Employee             ~ Other
~   DFRC Farm - 8396 Yellowstone, Marshfield
~   VCRU - 1575 Linden Drive				SUPERVISOR NAME:	
~   VCRU - Russell Labs - 1630 Linden Drive		
~   VCRU - Sturgeon Bay - 4312 Hwy 42, SB			
~   FISH - GLWI, 600 E. Greenfield Ave, MKE		

~   FAX COPY OF THIS REPORT TO LAO		~ Requires Workers Comp CA-1 Form to
      AT 608/890-0048 WITHIN 24 HRS 				Be Completed	
      OF INCIDENT/ACCIDENT
											
RETURN REPORT TO YOUR SUPERVISOR WITHIN 24 HRS OF INCIDENT
Date and Time of Incident or Accident	
Date________________ (Month/Date)     ~ Mon  ~ Tues ~ Wed ~ Thur ~ Fri ~ Sat ~ Sun     
Time _______________  ~ AM   ~ PM      	
Location of Incident or Accident	
~  Lab (Rm#______)       ~ Office (Rm #______)     ~ Farm                ~ Hallway                ~ Stairway
~ Other (specify):___________________________________________________________________	
Type of Incident or Accident  (check all that apply)	
~   Fire/biological/chemical/radiological
      (Specify type) ___________________________________________________________________
~   Spill/environmental release/contamination/hazardous material
      (Specify type) ___________________________________________________________________    
~   Security/vehicle accident/equipment accident/other property damage
      (Specify type) ___________________________________________________________________
~   Personal contamination/injury/fall
      (Specify type) ___________________________________________________________________
~   Other (specify) ________________________________________________________________	
Description of Incident/Accident	

	
Description of Contributing Factors and Employee Suggestion
How to Improve Process to Avoid Future Occurrence	

	

Notifications Completed at Time of Incident/Accident	
~   Fire                   ~    Ambulance           ~   Police/Sheriff         ~ Hazmat                ~ UW-Security
~   Supervisor        ~    Research Leader  ~  Family Member (specify):__________________________ 	
Witnesses to the Incident/Accident 	
1. __________________________         2.______________________________

3. __________________________         4. _____________________________
	
Action Causing Incident	
9  Slippery/wet/icy surface                        9  Reaching for object                     9  Operating Equipment
9  Footwear (shoes, sandals, bare feet)   9  Protective Equipment not used   9  Providing Assistance
9   Faulty Equipment                                 9  Not using proper equipment       9  Unsafe act                       9  Bodily defect or prior injury                    9 Not following protocol                  9 Horseplay
9  Other__________________________________________________________________________
__________________________________________________________________	
Type of Injury	
9  Respiratory         9  Muscular            9  Skin Related                   9 Skeletal           9  Puncture
9  Burn                    9 Poisoning            9  Bruise/Contusion            9  Cut/Laceration/Abrasion    
9  Other _____________________________________________________________
___________________________________________________________________	
Specific Body Area of Injury (circle right or left)	
9   Head             9  Neck             9  Shoulder  (R  L)       9  Arm   (R  L)    9   Hand (R L)    9  Wrist (RL) 
9  Elbow (R L)    9  Leg  (R L)     9   Knee (R L)              9  Ankle (R L)     9  Foot (R L)      9  Eyes (R L)
9   Back              9  Hip (R L)       9 Internal                     9  Other

	
Clean-up or Corrective Action Taken at Time of Incident/Accident (if any)	

	
Signature/Date of Person Completing Report	
Signature:                                                                             Date:	

USDA-ARS-MWA-Madison Location		  	             INCIDENT/ACCIDENT 
	 SUPERVISOR REPORT (IR-S-2006)
Specify Unit Location:
~   CCRU - 502 N. Walnut Street			TO BE COMPLETED BY SUPERVISOR:
~   CCRU - Russell Labs - 1630 Linden Drive			
~   DFRC - 1925 Linden Drive
~   DFRC Farm - S8822 State Rd Hwy 78, PDS 	NAME
~   DFRC Farm - , 8396 Yellow Stone, Marshfield
~   VCRU - 1575 Linden Drive				(Forward completed report along with
~   VCRU- Russell Labs - 1630 Linden Drive		incident report to Administrative Office)
~   VCRU-Sturgeon Bay - 4312 Hwy 42, SB
~   FISH - GLWI, 600 E. Greenfield Ave, Milwaukee			
													
SUPERVISOR REPORT BASED ON ATTACHED INCIDENT/ACCIDENT REPORT
Incident/Accident Report Information (attach report)	
Employee Name: __________________________________________________

Date________________ (Month/Date)    Time _______________  ~ AM   ~ PM

Date Incident/Accident Report Received from Individual: _____________________	
Incident/Accident Report Supervisor Verification	
1.  Was report filed in timely manner?  ~ Yes    ~   No

2.  Was the Supervisor notified immediately?  ~ Yes    ~ No

3.  Was the SHEM Committee Member for the Management Unit notified?  ~ Yes   ~ No

     Name of Committee Member: ______________________________________________________

4.  Was the Research Leader for the Management Unit notified?   ~ Yes    ~ No
 
5.  Did the incident/accident require medical attention?  ~   Yes     ~ No

     If so, please explain where individual sent: ____________________________________________

     ______________________________________________________________________________

6.  Did the individual complete Workers Compensation Form CA-1 in Admin Office within 24 hours of 
     incident/accident involving personal or potential personal injury?     ~ Yes     ~ No

     (Note: Copy of report, CA-1 & medical reports must be maintained in 30-year employee OSHA file.)   

7.   Were any difficulties encountered in responding to incident/accident?  ~ Yes   ~ No

      If so, please explain:   _____________________________________________________________
  
      _______________________________________________________________________________
	
Supervisor Analysis of Incident/Accident	
1.  Does the employee report accurately reflect the situation?   ~ Yes    ~ No
     If not, please explain: ______________________________________________
     ______________________________________________________________________________
     ______________________________________________________________________________
	
Actions Taken to Avoid Repeat Occurrence	
1.  Is additional or repeat training required of employee?  ~ Yes     ~ No
     If yes, when has the training been scheduled?   (Please specify when/where)

     __________________________________________________________________________

2.  Does the action require a change in protocol or procedure to avoid future reoccurrence?  
     ~   Yes     ~ No

     If yes, please explain: ________________________________________________________

     __________________________________________________________________________

     __________________________________________________________________________

3.   Is the change in protocol or procedure to be lab specific or is the recommendation to implement
      change location-wide?   ~ Lab Specific      ~   Location-wide

4.  Has the change in protocol/procedure been documented?  ~ Yes   ~   No

     Has the change in protocol/procedure been recommended for incorporation into the Lab’s Chemical
     Hygiene Plan?   ~ Yes     ~ No

5.  Has the change in protocol/procedure been communicated to personnel?       ~ Yes   ~ No

     How are personnel to be trained in new protocol/procedure.  Please explain:

     ________________________________________________________________________

     ________________________________________________________________________

     ________________________________________________________________________

     ________________________________________________________________________

     ________________________________________________________________________

6.  Other Comments:   ________________________________________________________

     ________________________________________________________________________

     ________________________________________________________________________

     ________________________________________________________________________

     ________________________________________________________________________

     ________________________________________________________________________

     ________________________________________________________________________

     ________________________________________________________________________
	
Supervisor Signature	
Signature:                                                                             Date: