AA Accident Incident Investigation Form

• Document No.

• Date and Time of Incident

  Date

• Accident Incident Investigation Form Prepared by (full name, employee ID, position)

• Date and Time Accident Incident Investigation Form was initiated

  Date

• Area / Location of Accident

  Select Employee Break Room Restroom Fresh Air High Value Cage Storage Cage IT Server Room Packing Station Battery Charging Station Loading Dock Trailer Bed Employee Parking Area Outdoor Employee Break Area Unit Sorter Web Packaging Wholesale Packaging C-Stage Wholesale Office Wholesale Customer Waiting Area Picking Aisles

  • Employee Break Room
  • Restroom
  • Fresh Air
  • High Value Cage
  • Storage Cage
  • IT Server Room
  • Packing Station
  • Battery Charging Station
  • Loading Dock
  • Trailer Bed
  • Employee Parking Area
  • Outdoor Employee Break Area
  • Unit Sorter
  • Web Packaging
  • Wholesale Packaging
  • C-Stage
  • Wholesale Office
  • Wholesale Customer Waiting Area
  • Picking Aisles

• undefined

  Select Aisle 1 Aisle 2 Aisle 3 Aisle 4 Aisle 5 Aisle 6 Aisle 7 Aisle 8 Aisle 9 Aisle 10 Aisle 11 Aisle 12 Aisle 13 Aisle 14 Aisle 15 Aisle 16 Aisle 17 Aisle 18 Aisle 19 Aisle 20 Aisle 21 Aisle 22 Aisle 23 Aisle 24 Aisle 25 Aisle 26 Aisle 27 Aisle 28 Aisle 29 Aisle 30 Aisle 31 Aisle 32 Aisle 33 Aisle 34 Aisle 35

  • Aisle 1
  • Aisle 2
  • Aisle 3
  • Aisle 4
  • Aisle 5
  • Aisle 6
  • Aisle 7
  • Aisle 8
  • Aisle 9
  • Aisle 10
  • Aisle 11
  • Aisle 12
  • Aisle 13
  • Aisle 14
  • Aisle 15
  • Aisle 16
  • Aisle 17
  • Aisle 18
  • Aisle 19
  • Aisle 20
  • Aisle 21
  • Aisle 22
  • Aisle 23
  • Aisle 24
  • Aisle 25
  • Aisle 26
  • Aisle 27
  • Aisle 28
  • Aisle 29
  • Aisle 30
  • Aisle 31
  • Aisle 32
  • Aisle 33
  • Aisle 34
  • Aisle 35

AMERICAN APPAREL ACCIDENT INCIDENT INVESTIGATION FORM

La Mirada Distribution Center 16322 - 16400 Trojan Way La Mirada, CA 90638

PERSONAL INFORMATION (injured employee)

• Injury or Incident

  Select Injury Incident

  • Injury
  • Incident

• Type of Injury

  Select Slip and Fall Near Miss Laceration Burn Sprain Abrasion or Bruise Strain Fracture Struck by Collapsing Object/Material Contact by Electrical Current Heat Exhaustion Contact or Exposed to Harmful Substances Struck by Forklift or Mobile Equipment Contusion Irritation Muscle Cramp Dislocation

  • Slip and Fall
  • Near Miss
  • Laceration
  • Burn
  • Sprain
  • Abrasion or Bruise
  • Strain
  • Fracture
  • Struck by Collapsing Object/Material
  • Contact by Electrical Current
  • Heat Exhaustion
  • Contact or Exposed to Harmful Substances
  • Struck by Forklift or Mobile Equipment
  • Contusion
  • Irritation
  • Muscle Cramp
  • Dislocation

• Source

  Select Machine, Tool, and Electric Parts Hand Tools - Powered Hand Tools - Non Powered Fasteners, Connectors, Ropes, Ties Furniture and or Fixtures Ladders Wet Floor Slippery Floor Dishes, Drinking Cups, Beverage Glasses Loose Fixture / Object Material Handeling On Break

  • Machine, Tool, and Electric Parts
  • Hand Tools - Powered
  • Hand Tools - Non Powered
  • Fasteners, Connectors, Ropes, Ties
  • Furniture and or Fixtures
  • Ladders
  • Wet Floor
  • Slippery Floor
  • Dishes, Drinking Cups, Beverage Glasses
  • Loose Fixture / Object
  • Material Handeling
  • On Break

• Single or Married

  Select Single Married

  • Single
  • Married

• Employee's Full Legal Name

• Employee Badge or Photo

  Media

• Employee ID#

• Date of Hire

• Social Security #

• Address (street address only)

• City, State, Zip Code

• Telephone

• Insurance

  Yes

  No

  N/A

• Number of dependents

• Sex

  Select Male Female

  • Male
  • Female

• Date of Birth

• Scheduled shift at the time of the accident

• Was the injured employee on overtime?

  Yes

  No

  N/A

• Employee's job title when injured

• Employee's hourly rate/salary

• How long has the employee been in this position?

• Employee's regular job title (if different)

• Employee's regular hourly rate/salary (if different)

• How long has the employee been in this position (if different)?

Completing this section of the form is required if the injury involved the use of mechanical equipment or any type of tool.

• Source

  Select Employee Break Room Restroom Fresh Air High Value Cage Storage Cage IT Server Room Packing Station Battery Charging Station Loading Dock Trailer Bed Employee Parking Area Outdoor Employee Break Area Unit Sorter Web Packaging Wholesale Packaging C-Stage Wholesale Office Wholesale Customer Waiting Area Picking Aisles

  • Employee Break Room
  • Restroom
  • Fresh Air
  • High Value Cage
  • Storage Cage
  • IT Server Room
  • Packing Station
  • Battery Charging Station
  • Loading Dock
  • Trailer Bed
  • Employee Parking Area
  • Outdoor Employee Break Area
  • Unit Sorter
  • Web Packaging
  • Wholesale Packaging
  • C-Stage
  • Wholesale Office
  • Wholesale Customer Waiting Area
  • Picking Aisles

• Machine # or Model or Type of Tool

• Take photo of the Machine, Tool, or other source object involved in the accident

  Media

• Part of machine where the accident occured?

• Was the machinery in use at the time of the accident?

  Yes

  No

  N/A

• Was the safety device or the Lock Out Tag Out procedure followed?

• Was the the accident caused by the injured employee's failure to follow safety procedures or the Lock Out Tag Out procedure?

  Yes

  No

  N/A

ACCIDENT / INCIDENT SUMMARY

• Specific job performed at the time of the accident?

• Body Part Injured

  Select Head Neck Eye Left Ear Right Ear Face Lip Tooth Chest Upper Back Area Lower Back Area Side of Body Left Shoulder Left Arm Left Elbow Left Wrist Left Hand Left Hand Finger(s) Right Shoulder Right Arm Right Elbow Right Wrist Right Hand Right Hand Finger(s) Groin Left Leg Right Leg Left Knee Right Knee Left Leg Calf Right Leg Calf Left Ankle Right Ankle Right Foot Right Foot Toe(s) Left Foot Left Foot Toe(s)

  • Head
  • Neck
  • Eye
  • Left Ear
  • Right Ear
  • Face
  • Lip
  • Tooth
  • Chest
  • Upper Back Area
  • Lower Back Area
  • Side of Body
  • Left Shoulder
  • Left Arm
  • Left Elbow
  • Left Wrist
  • Left Hand
  • Left Hand Finger(s)
  • Right Shoulder
  • Right Arm
  • Right Elbow
  • Right Wrist
  • Right Hand
  • Right Hand Finger(s)
  • Groin
  • Left Leg
  • Right Leg
  • Left Knee
  • Right Knee
  • Left Leg Calf
  • Right Leg Calf
  • Left Ankle
  • Right Ankle
  • Right Foot
  • Right Foot Toe(s)
  • Left Foot
  • Left Foot Toe(s)

• Body Part Injured - Was the Injury Report form documenting the injured body part completed and signed by the injured employee?

  Yes

  No

  N/A

• Take a photo of the section of the Injury Report form that the injured employee circled indicating the part of their body that was injured.

  Media

• If applicable, take photos of the body part(s) injured

  Media

• Photos of body part(s) injured taken?

  Yes

  No

  N/A

• On a scale between 1 and 10, 1 indicating No Pain and 10 indicating Major Pain, how least or great is the injured employee's pain?

• Take photos of the area where the accident occured.

  Media

• Photos of the area where the accident took place taken?

  Yes

  No

  N/A

• DWC form completed and signed by both the injured employee and employee documenting the accident?

  Yes

  No

  N/A

• Was the injured employee provided a copy of the DWC form?

  Yes

  No

  N/A

• Was the Supervisor's Investigation of Injury form completed?

  Yes

  No

  N/A

• If the injured employee refused medical treatment, did the injured employee complete and sign the Refusal of Medical Treatment form?

  Yes

  No

  N/A

• Accident / Incident Sequence (describe the order of events or job steps before the accident or injury)

• Accident / Incident Causes (list any failure in following procedure, use of equipment, equipment malfunction, material handling, lack of training or any other cause that explains the events that led to the accident or injury)

• Provide a drawing that illustrates how that accident occurred (if applicable)

  Drawing

• What type of immediate medical attention if any was the injured employee provided?

  Select First Aid Treatment on site Transported to the authorized Immediate Medical Center Transported by paramedics to a local hospital Refused all and any medical attention

  • First Aid Treatment on site
  • Transported to the authorized Immediate Medical Center
  • Transported by paramedics to a local hospital
  • Refused all and any medical attention

• If the injured employee was transported to the hospital, which hospital was the employee taken to? Provide the name of the hospital, city and telephone number.

SIGN and DATE

Witness Information

• Witness Full Legal Name

• Witness Employee ID#

• Witness Employee Badge or Photo

  Media

• Witness narrative of Injury/Incident

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony. I, employee, the undersigned, certify that the above is true and correct statement of fact and that I made such statements of my own free will. American Apparel will prosecute to the fullest jurisdictional extent for all fraudulent claims. Todo aquella persona que a proposito haga o cause que se produzca cualquier declaracion o representacion material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacion a trabajadores lesionados es culpable de un crimen mayor "felonia". Yo el empleado certifico que lo mencionado arriva es verdad y correcto y que he hecho estos reportes en mi libre voluntad. American Apparel levantra cargos al grado maximo juridiccional por caulquier reporte fraudulento.

• Name / Signature of Employee - Nombre en letra de molde / Firma del Empleado

  Sign

• Name / Signature of Supervisor - Nombre de Supervisor / Firma del Supervisor

  Sign

• Name / Signature of Department Manager - Nombre del gerente del departamento / Firma del gerente del departamento

  Sign

• Name / Signature of Witness Employee - Nombre en letra de molde testigo / Firma del Empleado

  Sign