University of California, Berkeley
Injury and Illness Prevention Program (IIPP) Template and Forms

Departments at the University of California, Berkeley can use the template and forms (including self-assessment forms) listed below to create a written Injury & Illness Prevention Program (IIPP) that meets the requirements of state law. (Each department at UC Berkeley is required to have its own IIPP.) The template and forms help your department document its safety activities, an important part of implementing your IIPP. Putting the written program into action will help to ensure a healthful and safe workplace for department employees. If you have comments or suggestions on the IIPP template or forms, contact Steve Maranzana at This email address is being protected from spambots. You need JavaScript enabled to view it. or 643-1208. The next step is to put the program into action. An IIPP's benefits will be realized only through effective implementation.

 

  Number Title Word PDF
    IIPP Template (does not include forms) Word PDF
  Form 1 Report of Unsafe Condition or Hazard Word PDF
  Form 2 Safety Committee Meeting Documentation Word PDF
Self-
Assessment
Forms
Form 3-Lab Laboratory Safety Self-Assessment Word PDF
Form 3-Gen'l General Safety Self-Assessment Word PDF
Form 3-Office Office Safety Self-Assessment Word PDF
Form 3-Shop Shop Safety Self-Assessment Word PDF
Form 3-Storage Storage Space Safety Self-Assessment Word PDF
For DSCs Only 2013 Laboratory and Shop Safety Self-Assessment Program Summary Form Word PDF
  Form 4 Hazard Correction Report Word PDF
  Form 5 Occupational Accident , Injury or Illness Investigation Report Word PDF
  Form 6 Safety Training Attendance Record Word PDF
  Form 7 New Employee Safety Training Record Word PDF

To use the IIPP Template
To use the IIPP template, first download it and the applicable forms. (See "Downloading Tips" below.) Once the template is open on your own workstation, read through the entire document and fill in the blanks found on the first two pages with your department's specific information. Print copies of the forms for your department's use. (The forms are generic and do not require any changes.) When you're done, send a copy to the Office of Environment, Health & Safety (EH&S) at 317 University Hall #1150 for review. (You may also send it as an email attachment to This email address is being protected from spambots. You need JavaScript enabled to view it. . EH&S will review the draft against applicable legal requirements.

To use the Forms
There are three ways to view and use the forms:
1) Word File - Download a Word file if you want to have the form on your computer. With a Word file you are able to open the file and add or change the content before printing it out.
2) PDF - Download a PDF (Portable Document Format) file if you want a formatted document that you can print out to your local printer. With a PDF file you will not be able to make changes to the document.
3) View Online - Click on link to view document on the web.

Related Links
Injury and Illness Prevention Program (IIPP) - Provides program overview, resources and assistance.

Downloading Tips
The documents you will be downloading were created in Microsoft Word. They can be downloaded by Macintoshes, PCs, and Unix systems. Downloading them will be easiest if your browser's preferences for helper applications are properly set. You can set helper application preferences to launch your word processing application upon receiving the documents or to save them to any location you choose.

If your downloading results in a plain document icon, start your word processing application, then use its "Open" command to open the file. Macintosh users should note that the IIPP file is too big to open through Simple Text.

If you'd like technical assistance in downloading these files, contact Cheryl Reinman of EH&S by This email address is being protected from spambots. You need JavaScript enabled to view it. or telephone at 642-1978.