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
- press
- finishing
- warehouse
- shipping
- sheeting
- maintenance
- plate room
- exterior grounds
- UC Warehouse
- office area
PERSONAL INFORMATION (injured employee)
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Employees full name
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Enter date and time of injury or accident
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Date of birth
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Take picture of 1.) Incident Report. 2.) Page 1 FDC Incident/ Investigation Report
Manager / Safety Team Investigation
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Employment Category
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Length of employment
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Time in occupation at time of incident
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Type of operation
- production
- maintenance
- set-up
- cleaning
- unjamming
- other
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Was this operation a regular part of employees job?
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Time associate reported to work on date of incident?
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Type of injury
- No injury
- First Aid
- Medical Treatment
- Lost Time
- Restricted Duty
- Fatality
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Does equipment have lockable disconnect?
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Name and title of person who assigned task/job
ACCIDENT / INCIDENT SUMMARY
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How long since a supervisor was in area of incident and who?
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We're there any witnesses to the incident? What are the witnesses names?
Accident Sequence - describe in reverse order the occurrence of events preceding the injury
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Injury Event / Accident Event
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Describe the preceding events that led up to the injury or accident
Preceding Events
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Was PPE required for this task?
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What PPE was required and in use at time of incident
PPE REQUIRED
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Provided?
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Trained on proper use?
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Proper use of PPE?
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PPE use enforced by manager and supervisor?
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Was equipment adequately guarded? If no describe deficiency
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Has employee received training prior to job assignment?
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Who performed training?
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What was the duration of the training?
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Was training adequate?
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Was lockout necessary?
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Was employee trained?
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Was training adequate?
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Was lock provided?
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Was written procedure required?
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Was procedure provided to follow?
QUESTIONNAIRE
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Where were you at the time of the incident?
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What time did the incident occur?
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What were you doing at the time of the incident
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What injury resulted from the incident?
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Was there any ergonomic (strain/sprain) from the incident?
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We're any Pre-existing conditions with the injury area?
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Did you have to
- Push
- Pull
- Bend
- Twist
- Lift
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If moving a object what was the estimated weight?
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Did you ask for help with lifting?
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Demonstrate how the task was performed
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Could you have done anything different to prevent the injury?
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Was there a laceration incident
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What type of equipment or tool was used?
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We're there any know issues with the equipment/tool not functioning properly?
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Demonstrate how the task was performed
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Could you have done anything different to prevent the injury?
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Was there a trauma incident?
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Did a trip, slip, bump, falling object cause the incident?
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Was a ladder involved?
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What type?
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Where were your feet placed on the ladder?
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Was the ladder inspected as part of the Fall Protection Program?
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We're there any safety restraints in place?
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Demonstrate how the task was performed
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How could this incident been prevented?
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How often do you perform this task?
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Are there any specific PPE requirements for the task and were they used?
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Was training provided for this task?
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Were any safety mechanisms by-passed?
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After your involvement with this incident, is there any insight you could share or preventative actions you would recommend?
CONCLUSION / ROOT CUASE
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Enter conclusions
CORRECTIVE ACTIONS REQUIRED
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Enter all correct preventative actions that will be implemented
PICTURES & DRAWINGS
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Add media
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Add drawing
SIGN and DATE
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Name / Signature of Employee
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Name / Signature of Supervisor
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Name / Signature of Department Manager
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Name / Signature of Safety Team Lead
