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. Putting the written program into action will help to ensure a healthful and safe workplace for department employees. Heat Illness Prevention Program. Heat Illness Prevention Program Template. INJURY & ILLNESS PREVENTION PLAN (IIPP) University of California Riverside (UCR) Injury & Illness Prevention Plan (IIPP) describes specific requirements for program. If you have comments or suggestions on the IIPP template or forms, contact Brandon De. Francisci at defran@berkeley. 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. PDF Form 1. Report of Unsafe Condition or Hazard. Word PDF Form 2. Safety Committee Meeting Documentation. Word. PDFSelf- Assessment. Forms Form 3- Lab. Laboratory Safety Self- Assessment PDFForm 3- Gen'l. General Safety Self- Assessment. Word. PDFForm 3- Office. Office Safety Self- Assessment. Word. PDFForm 3- Shop. Injury and Illness Prevention Program. The sample form templates provided. Injury & Illness Prevention Program. Injury & Illness Prevention program. Injury & Illness Prevention Program OEHS Template. Shop Safety Self- Assessment. Shop Self- Assessments for the 2. February 2. 01. 5. Form 3- Storage. Storage Space Safety Self- Assessment. Word. PDFFor DSCs Only. Laboratory and Shop Safety Self- Assessment Program Summary Form 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. PDFTo 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. EH& S will review the draft against applicable legal requirements. Related Links. 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 6. Injury and Illness Prevention Program. Injury and Illness Prevention Program Creator. This website creates an Injury and Illness Prevention Program for your business.
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