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 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 PDF
  Form 1 Report of Unsafe Condition or Hazard Word PDF
  Form 2 Safety Committee Meeting Documentation Word PDF
Form 3-Lab Laboratory Safety Self-Assessment   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 Shop Self-Assessments for the 2014/2015 academic year will be conducted in February 2015.
Form 3-Storage Storage Space Safety Self-Assessment Word PDF
For DSCs Only 2014 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 PDF

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 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 642-1978.