Safety Health and Environment Department

UZ Main Campus, Tetuan, Zamboanga City

(63)(62) 991-1135 {221}

ACCIDENT/ INCIDENT/ NEAR MISS

INVESTIGATION FORM
PART A - Form Details
Person Completing the Form

Person Type: Casual Student Employee Contractor Visitor

First Name: Crystal Ann Surname: T a d i a m o n

Department: UZ Pagadian Job Title: MIS Staff

Report to be sent to

Supervisor:

Incident Details

Incident Type: Incident - With Injury Incident - Without Injury Near Miss

Description of Incident/Accident/Near Miss:

On January 12, 2022, the SAM- Medtech 4th year students were scheduled for an on-site examination
held at the UZP Function Hall.  The said on-site examination composed of 2 groups with 8 persons per
group with a total of 16 persons. All of the 16 students enter the campus at exactly 8am in the morning
and went home at exactly 5pm in the afternoon.

During lunch break session, The 16 students together with the SAM Med Tech Faculty took their lunch
break at the Function Hall of University of Pagadian and it was monitored that no protocol of physical
distancing has been observed.

After the examination in the afternoon. Eight (8) students reported to the office of the UZP Administrator
for the request of the travel to Ozamis City for their internship.

The 8 (eight) students underwent COVID-19 Antigen Test as instructed by UZP Administrator as
protocol for their request.

Based on the results of the Antigen test, 2 of the students had a POSITIVE antigen test result.

Upon conducting the investigation, It was being identified that one of the students who took the
examination falsified his/her health declaration as a healthy individual.

Beforehand, the said student was a close contact of a positive patient which was identified as his/her
uncle.

Location(Bldg.,Room No., Floor No.): Function Hall

Date of Incident:1-12-2022 Time of Incident: 8:00am- 5:00pm Date Reported: 1-13-2022

Treatment:
None
First Aid
Clinic
Hospital
 Safety Health and Environment Department
UZ Main Campus, Tetuan, Zamboanga City
(63)(62) 991-1135 {221}

Name of the First Airder/Treatment Provider:

 PART B - Injury Details Only for ‘Incident - With Injury’. Otherwise proceed to Part C

Injured Person

First Name: Surname:

Contact No: Department/College:

Description of Illness/Injury:

PART C - Corrective Actions

Corrective Action/s Description: (What will be done to minimize the risk of happening again)

Re-orientation of Campus Preparedness guidelines-

UZP to revisit HIRAC - to include on site examination activities
Safety Officer to monitor on site activities

Person Involved: April Jane P. Amad,Edam P. Bayawa,Arlyn P. Bongcawil,Mary Jane S.

Borces,Krstyl-Eilyn A. Cabañog,Mary Angelique B.  Caguindangan,Hannah Mari L. Espiga,Ma.
Clarence S. Glodove,Shelly Pierre A. Gomez,Bainor T. Kuri,Nada M. Pango Ronna Mae S.
Picpic,Aliah Ira B. Polanco,Renzo Paul B. Tamula,Angle DB P. Tan,Sarah Lie l. Yator,Aia kay
Salinding Eduard Danda

Action/s completed: Yes No, Target date for completion:

Remarks: to be filled up by the Safety Officer

FO-SHED-001; Revision 0; October 06,

2021
Crystal Ann M. Tadiamon,RN
Name & Signature

01/13/2022
Date