Information
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Document No.
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Date and Time of Incident
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Accident Incident Investigation Form Prepared by (full name, employee ID, position)
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Date and Time Accident Incident Investigation Form was initiated
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Area / Location of Accident
- Building 1
- Building 2
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- 1st Floor
- 2nd Floor
- 3rd Floor
- 4th Floor
- 5th Floor
- 6th Floor
- 7th Floor
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- North-West Fabric
- North-East Fabric
- North Fabric
- South End Restroom
- North End Restroom
- North End Stairway
- North End Dock
- North End Alley
- Mid-Section Alley
- South End Alley
- Air Compressor Room
- Electrical Room
- Stairway 1
- Stairway 2
- Stairway 3
- Elevator 1
- Elevator 2
- Elevator 3
- Elevator 4
- Elevator 5
- Elevator 6
- QC Lab
- Fabric Control Office
- Showroom
- Will Call
- Security Lobby
- Boutique Store
- North End
- North West
- North East
- Mid-Section
- Mid-West
- Mid-East
- Hosiery Office
- Hosiery - Pantyhose
- Hosiery - Gloves
- Hosiery - Socks
- Knitting Area
- Creative Dept.
- Restrooms
- Marketing Dept.
- Retail Print Shop
- North End Stairway
- Mid Stairway
- South End Stairway
- Cutting Area
- North-End Cutting
- Mid-Section Cutting
- South-End Cutting
- North-End Sewing
- Mid-Section Sewing
- South-End Sewing
- Machine Shop
- Recycling Dept.
- Steam//Hat Area
- In-House Labeling
- Grading Dept./Cutting
- Cutting Office
- Kuris Machine
- Trim Dept.
- Bundling Dept.
- Lunch Area
- North-West Sewing Area
- North-East Sewing Area
- North Sewing
- Web Dept.
- Software Development
- Graphics
- IT Solutions
- Helpdesk (IT)
- Asset Protection
- Health & Safety
- Clinic (Elite Medical Clinic)
- Food Vendor Area
- Legal Office
- Human Resources
- Benefits
- Payroll
- Conference Room
- by Conference Room
- Photo Studio
- Division Lead Office
- Near HR, Clinic & Health & Safety
- Near Payroll & Benefits
- South-End Restrooms
- Mid-Section Restrooms
- North-End Restrooms
- Server Room
- Mid-East Sewing Area
- Mid-West Sewing Area
- South-West Sewing Area
- North-West Sewing Area
- South Sewing Area
- Isla Office (Priscila's Office)
- Isla Dept.
- Packing Dept.
- Production Office
- Mechanics Office
- Mechanics Shop (Mechanics)
- Accounting Office
- Finance Dept.
- Reception Area
- Customer Service
- Showroom
- Product Development
- Product Planning
- Sample Library
- Retail Dept.
- Quality Control
- Maintenance/Housekeeping
AMERICAN APPAREL ACCIDENT INCIDENT INVESTIGATION FORM
American Apparel Headquarters (AAHQ) 747 Warehouse Street Los Angeles, CA. 90021
PERSONAL INFORMATION (injured employee)
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Injury or Incident
- Injury
- Incident
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Type of Injury
- 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
- Puncture
- Repatative Motion
- Insect Bite
- Personal Incident
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Source
- 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
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Single or Married
- Single
- Married
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Employee's Full Legal Name
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Employee Badge or Photo
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Employee ID#
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Date of Hire
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Social Security #
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Address (street address only)
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City, State, Zip Code
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Telephone
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Insurance
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Number of dependents
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Sex
- Male
- Female
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Date of Birth
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Scheduled shift at the time of the accident
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Was the injured employee on overtime?
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Employee's job title when injured
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Employee's hourly rate/salary
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How long has the employee been in this position?
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Employee's regular job title (if different)
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Employee's regular hourly rate/salary (if different)
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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.
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Source
- Building 1
- Building 2
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Machine # or Model or Type of Tool
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Take photo of the Machine, Tool, or other source object involved in the accident
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Part of machine where the accident occured?
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Was the machinery in use at the time of the accident?
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Was the safety device or the Lock Out Tag Out procedure followed?
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Was the the accident caused by the injured employee's failure to follow safety procedures or the Lock Out Tag Out procedure?
ACCIDENT / INCIDENT SUMMARY
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Specific job performed at the time of the accident?
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Body Part Injured
- 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)
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Body Part Injured - Was the Injury Report form documenting the injured body part completed and signed by the injured employee?
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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.
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If applicable, take photos of the body part(s) injured
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Photos of body part(s) injured taken?
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Take photos of the area where the accident occured.
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Photos of the area where the accident took place taken?
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DWC form completed and signed by both the injured employee and employee documenting the accident?
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Was the injured employee provided a copy of the DWC form?
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Was the Supervisor's Investigation of Injury form completed?
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If the injured employee refused medical treatment, did the injured employee complete and sign the Refusal of Medical Treatment form?
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Accident / Incident Sequence (describe the order of events or job steps before the accident or injury)
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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)
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Provide a drawing that illustrates how that accident occurred (if applicable)
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What type of immediate medical attention if any was the injured employee provided?
- 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
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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
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Witness Full Legal Name
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Witness Employee ID#
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Witness Employee Badge or Photo
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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.
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Name / Signature of Employee - Nombre en letra de molde / Firma del Empleado
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Name / Signature of Supervisor - Nombre de Supervisor / Firma del Supervisor
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Name / Signature of Department Manager - Nombre del gerente del departamento / Firma del gerente del departamento
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Name / Signature of Witness Employee - Nombre en letra de molde testigo / Firma del Empleado