Forms

Accidents and Incidents

All accidents, injuries, or conditions that may cause harm should be reported to the university so that appropriate remediation or corrective measures can be taken to protect the university community from similar or future incidents. The following situations should be reported to the university:

  • Employee Accident: An Incident Report Form should be completed whenever an accident (that does not result in injury), theft of university property, fire on university property, or unsafe condition occurs.
  • Student or Visitor Accident or Injury: An Incident Report Form should be completed whenever an accident, injury, or unsafe incident occurs involving a university student or visitor. 
  • University Property Damage: Damage to university property resulting from accident or emergencies must be reported to the Office of Risk Management via the Report of Loss to State Owned Property form.
  • University/State Vehicle Accident: If you are involved in an automobile accident involving a university-owned vehicle you must complete an Automobile Loss Notice Form and submit it to the Office of Risk Management. If you are still at the scene, review the instructions on the envelope in the glove box of the state vehicle.

The forms listed above are used to investigate unsafe conditions, identify corrective actions to prevent accidents and incidents, and modify programs accordingly to improve safety on university property.

For more information regarding workplace injuries, exposures, or illnesses, please review the University Accident and Incident Plan. For questions regarding workers’ compensation please contact Human Resources and Payroll Workers’ Compensation at 703-993-7756. For information about insurance, university property damage/theft, and automobile incidents contact the Office of Risk Management at 703-993-2599.

Confined Space

Confined Space Entry Permit

Please review the Confined Space Plan for more information on how to complete this form. Contact EHS with any questions or concerns about confined space entry.

Alternate Confined Space Entry Procedure Certification

The completed Alternate Entry Procedure Certification form must be posted at the entry point in addition to the Confined Space Entry Permit (above) and be available for review for the duration of the confined space project.

Fall Protection

Please review the Fall Protection Plan for more information on how to complete this form. Contact EHS with any questions or concerns about fall protection.

Job Safety Analysis (JSA)

Job Safety Analysis (JSA) is a procedure that focuses on individual job tasks to identify hazards and prevent injury or exposure by employing appropriate engineering, administrative, physical controls, as well as personal protective equipment (PPE). The JSA process focuses on the relationship between the worker, the task, the tools, and the work environment. JSA document steps that must be taken to eliminate or reduce workplace hazards to an acceptable risk level. Please refer to the JSA Guide for help completing this form.

Lockout/Tagout (LOTO)

Supervisors are responsible for maintaining the following records in order to meet the requirements of the Lockout / Tagout Plan:

Machine and Machine Shop Safety

Please review the Machine and Machine Shop Safety Guide for more information on how to complete this form. Contact EHS with any questions.

Forklift Safety

Before operating a forklift, classroom and hands on training is required. For more information about how to operate a forklift safely, please reference the Forklift Safety Guide. To register for Powered Industrial Truck training please click here.

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