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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Part 1, Chapter 9:  Manual Appendix 1-9-A

Forms, Procedures and Standard Format for
Messages and Incident Reports

  1. Incident Reporting - General. (See IHM, Part 1, Chapter 9, Section 1-9.4 for definitions)
  2. Please note: A manual of instructions for incident reporting will be prepared separately.

    1. All incidents shall be reported using the IHS Incident Report form (IHS-516).  The report will be initiated by the employee or the supervisor having jurisdiction over the operation or function experiencing any incident involving patients, IHS personnel, visitors to IHS facilities including contractors, the general public, or property.  The Incident Report will then be submitted 6 days after receiving information on an incident to designated Safety Officers as follows:

      1. The original report is forwarded to and maintained by the Local OSH Officer for a minimum of 5 years.  A copy of all completed forms will be forwarded to and maintained by the Area OSH Officer at the Area Office.
      2. The originating facility OSH Officer will provide consecutive (beginning with number 001) case numbers for all incidents at each reporting facility, on October 1st of each fiscal year.  The employee injury and illness incidents will be used to compile the "Log of Federal Occupational Injuries and Illnesses."
      3. The IHS Headquarters OSH Manager will not be sent copies of incident reports.  Records will be maintained at the local facility.  Software generated reports will be used to supply the IHS OSH Manager with required reports on an annual basis.  The only exception is the message report and followup reports for serious incidents, which are submitted as soon as possible (see Manual Appendix 1-9-A, Part B.).  Fully completed copies of all related forms and information will be sent to the IHS OSH Manager.
    2. In the event Federal employees other than IHS personnel are injured during the course of their employment on or near IHS property, an original Incident Report will be prepared and forwarded to the supervisor of the agency at which the injured person is employed.  These cases are not to be included as part of the IHS incident experience.
  3. Serious Incidents, Injuries, and Illnesses.

    All serious incidents are to be reported to the IHS Headquarters OSH Manager within 8 hours.  Serious occupational incidents must be reported within 8 hours to the OSHA Office of Federal Agency Programs.  Non-occupational incidents are to be reported to IHS Headquarters as well but not to OSHA.

    Serious incidents include:

    1. Any incident which is fatal to one or more persons.
    2. Injuries requiring hospitalization to 3 or more employees.  Also injuries to 5 or more persons, including non-Federal employees, patients, the general public, and Federal contractors in a single incident resulting in provision of first-aid treatments.
    3. Any occupational illness that results in death.
  4. Property damage of $25,000 or more.
  5. All aircraft incidents reportable to the National Transportation Safety Board (NTSB) per Federal aviation regulations.
  6. Radiation overexposure that could result in a disabling injury.
  7. Biological exposure or unintentional release of biological substances where the public may be exposed.

    A message report will be sent immediately, via FAX or electronic mail, to the IHS OSH Manager who will notify the PHS Safety Officer and OSHA within 8 hours of any serious incident.  The message must address at least the following information:

    1. Names of individuals involved.
    2. Number of fatalities and/or injuries and illnesses and their extent.
    3. Establishment name, time, date, location, type of incident, and kind of operation conducted at the incident site.
    4. Actions taken by the IHS to investigate the incident and whether OSHA assistance is needed.
    Appropriate incident report forms will be prepared and forwarded to Headquarters through normal channels as soon as possible.  Completed copies of all available information (forms or other) will be sent to the IHS OSH Manager as soon as the information is available.
  8. Damage by Members of the Public.  If property damage (meeting definition 1-9.4.P) is accomplished by a member of the public (non-IHS personnel), an investigating officer (usually the supervisor of the affected department, an employee of the affected department, or the local OSH officer) shall be designated and through normal channels shall submit an Incident Report (IHS Form-516).  If employee property is damaged, (e.g. vandalism), the employee is to be given the information for filing a claim against the government to recover the loss or cost of damages.
  9. Specific Types of Incidents.

    Special procedures and report forms required are listed below:

    1. Aircraft Incident.  All aircraft incidents shall be investigated using the Incident Report and will require the submittal of a message report to the IHS OSH Manager.
    2. Motor Vehicle Incidents.  Motor vehicle incidents are to be investigated and reported promptly to IHS and GSA.  Tort claims often result from motor vehicle incidents (see Section 1-9.5 of this chapter); therefore, all incidents must be properly and completely documented (see Section 1-9.8 of this chapter).  Safety Officers and Investigating Officers shall become familiar with the Personal Property Management Manual, Chapter 6-200, Motor Vehicle Management, and the General Administration Manual Chapter PHS 4-30-10 A.1.b., A.2, and 4-30-47, A, B, and C.  The operator of the vehicle shall submit a completed Incident Report through the normal channels to the local OSH Officer.  Operators of Government vehicles or their supervisors will also notify GSA Fleet Management and complete the following as required by GSA:

      1. Data Bearing Upon Scope of Employment of Motor Vehicle Operator, Optional Form-26.
      2. Statement of Witness, Standard Form-94, shall be completed in all cases where witnesses are available.
      3. Operators Report on a Motor Vehicle Accident, SF-91.
      4. Investigation Report of Motor Vehicle Accident, SF-91A.
      5. Form HHS-342 - Report of Survey.  In instances where property is damaged, including motor vehicles, the supervisor must also report the property damage to the Property Officer in accordance with Property Boards of Survey procedures in IHM, Part 5, Chapter 12, Personal Property Management.

      NOTE:  In addition, all applicable State and local investigation/reporting forms should be completed within prescribed timeframes.
  10. Safety Review.

    A review of all workplaces including offices will be completed annually by the local hazard surveillance team.  The survey results shall be entered into the facility safety tracking system.  See Manual Exhibit 1-9-C, "Model Hazard Surveillance Program," for an example of a safety tracking system.
  11. Annual Report of the Safety Management Program.

    An annual report describing the previous fiscal year's OSH program will be prepared by each Area and submitted to the Headquarters OSH Manager by January 1st.  Format and report requirements will be provided by the Department of Health and Human Services.  The Area OSH Officer, shall provide a format for the annual reporting of safety activities to the service units and contract facilities at which Federal employees are stationed.
  12. Log of Occupational Injuries and Illnesses.

    Each establishment is required to keep a log of occupational injuries and illnesses.  This log should be completed 6 days after information about the incident has been received.  Also, yearly totals of all injuries, illnesses, and fatalities must be posted within 45 days from the end of the fiscal year and shall remain posted for 30 days.
  13. Medical Records.

    Record of treatment, examination, exposure, and any other occupational medical and related records that are filed in the employee medical file.  The purpose of occupational health medical records, as described in Manual Appendix 1-9-F, is to provide a complete record of employee health care for both medical and legal purposes.  If an employee receives any medical attention, a medical record must be generated.  The information will be kept in the employee's medical record in a separate section entitled "Employee Medical File" or "Employee Health Medical Record."
  14. FECA Claims.

    All incidents that result in an injury or illness to an IHS employee covered by FECA shall be reported as set forth in 20 CFR Parts 1-25.  Forms to be maintained at each IHS site for this purpose include:

CA-1:  Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation.

CA-2:  Notice of Occupational Disease and Claim for Compensation

CA-2a:  Notice of Employee's Recurrence of Disability and Claim for Pay/Compensation

CA-3:  Report of Termination of Disability and/or Payment

CA-5:  Claim for Compensation by Widow, Widower and/or Children

CA-5b:  Claim for Compensation by Parents, Brothers, Sisters, Grandparents or Grandchildren

CA-6:  Official Superior's Report of Employee's Death

CA-7:  Claim for Compensation Due to Traumatic Injury or Occupational Disease

CA-8:  Claim for Continuing Compensation on Account of Disability

CA-12:  Claim for Continuance of Compensation

CA-16:  Authorization of Examination and/or Treatment

CA-17: Duty Status Report

CA-20: Attending Physician's Report

CA-20b:  Attending Physician's Supplemental Report

Refer to Indian Health Manual, Part 1, Chapter 8, Managing the Workers' Compensation Program for more information on FECA claims.


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