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 Brandon DeFrancisci at firstname.lastname@example.org or 643-6394. The next step is to put the program into action. An IIPP's benefits will be realized only through effective implementation.
|Number||Title||Word file||PDF file|
|IIPP Template (does not include forms)||Word|
|Form 1||Report of Unsafe Condition or Hazard||Word|
|Form 2||Safety Committee Meeting Documentation||Word|
|Form 3-Lab||Laboratory Safety Self-Assessment||Word|
|Form 3-Gen'l||General Safety Self-Assessment||Word|
|Form 3-Office||Office Safety Self-Assessment||Word|
|Form 3-Shop||Shop Safety Self-Assessment||Word|
|Form 3-Storage||Storage Space Safety Self-Assessment||Word|
|For DSCs Only||2013 Laboratory and Shop Safety Self-Assessment Program Summary Form||Word|
|Form 4||Hazard Correction Report||Word|
|Form 5||Occupational Accident , Injury or Illness Investigation Report||Word|
|Form 6||Safety Training Attendance Record||Word|
|Form 7||New Employee Safety Training Record||Word|
To use the IIPP Template
To use the IIPP template, first download it and the applicable forms. 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 email@example.com. EH&S will review the draft against applicable legal requirements.
Injury and Illness Prevention Program (IIPP) - Provides program overview, resources and assistance.
If you'd like technical assistance in downloading these files, contact Cheryl Reinman of EH&S by e-mail or telephone at 642-1978.