Title Page

  • Document No.

  • Watson Electric Report

  • Conducted on

  • Prepared by

Employee Information

  • Accident Date / Time

  • Division:

  • Date report complete

  • Employee name

  • Employee identification number:

  • Job Title

  • Supervisor

  • Employee home address

  • Employee cell/home phone

  • If auto accident:

  • Watson Electric drivers description of accident:

  • Immediate drug screen performed

Automobile Accident

Automobile Accident

  • Auto accident:

  • Location of accident: street, city, state

  • Intersection if applicable:

  • Type of collision:

  • Photographs from accident scene:

  • Measurement of skid marks:

  • Skid marks made from other parties involved in accident:

  • Model and make of Watson Electric vehicle: No., year, make, model

  • Model and make of other vehicles: year, make, model

  • Weather factors:

  • Which driver was effected by the weather:

  • Comments:

Injuries

  • Did injuries occur:

  • Names and phone numbers of those injuries:

  • Were persons injured transported to a medical facility:

  • Mode of transportation:

  • Name of medical facility, address, state and phone number:

Eye witness information:

  • Name address phone cell/home

  • Eye witness description and diagram of accident:

  • Add media

  • Supervisors description and diagram of accident with any unusual findings: illegal substances, no drivers license with driver or attach photo.

  • Add media

  • Recommendations on correct action to prevent similar accidents:

  • Safety representative shall provide transportation for the employee to a drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).

  • Supervisors signature:

Burn

Burn Incident Report

  • Burn incident report

  • Date and time of Burn incident

  • Type of Burn:

  • Location of incident: job site, street, town, state

  • What type of electrical device caused the Burn:

  • Voltage was tested by:

  • What procedures were used to test the voltage?

  • Indicate measurement of voltage:

  • Rubber gloves worn by employee:

  • Glove test date:

  • List protective gear worn by employee:

  • We're rubber blankets used:

  • Rubber blanket test date:

  • We're there burn marks on the employees clothing:

  • Was employee knocked away from or remained connected to electrical force:

  • Photographs of area where incident occurred:

  • Photo

  • NOTE: ANY TOOL BEING USED NEEDS TO BE TURNED INTO THE SAFETY REPRESENTATIVE

Injuries

  • Did injuries occur?

  • Did employee lose consciousness?

  • Names and phone numbers of other injured in the accident:

  • Were persons injured transported to a medical facility:

  • Mode of transportation:

  • Name of Medical Facility, address, state, phone:

Eye witness information:

  • Name address, phone cell/home

  • Eyewitness description of accident or attached photo:

  • Photo

  • Supervisor description and diagram of Burn incident and unusual findings or attach photo:

  • Photo

  • Recommendations on corrective actions to prevent similar accidents:

  • Safety representative shall provide transportation for employee to drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours)

  • Supervisor Signature

Cut Line incident

Cut Line Incident

  • Cut line incident

  • Date / Time line was cut:

  • Type of line cut:

  • Location of cut line street, town, state

  • Intersection if applicable:

  • Was cut line active:

  • Was the cut line located in DOT right of way:

  • Photograph of cut line measured to locate mark with tape measure readable?

  • Photo

Locate information

  • Locate ticket number:

  • Name of person who called for the locate ticket:

  • Was update required for locate ticket?

  • Date of up dated locate ticket:

  • Name and phone number of persons updating the locate ticket:

Other Companies involved in project:

  • Name, address, city, state, phone number:

Injuries

  • Did injuries occur?

  • Names and phone numbers of those injured in the accident:

  • Were injured people transported to a medical facility:

  • Mode of transportation:

  • Name of Medical Facility, address, city, state, phone number:

Eye witness information:

  • Name, address, phone cell/home:

  • Eye witness description of accident or attached photo:

  • Photo

  • Supervisors description and diagram of cut line with unusual findings or attach photo. Show all marks with color description on diagram and note the date and time diagram was made.

  • Photo

  • Recommends on corrective action to prevent similar accidents:

  • Safety representatives shall provide transportation for the employee to drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours.

  • Supervisors signature:

Exposure Incident

Exposure Incident

  • Exposure incident

  • Date / Time of exposure:

  • Location of where exposure occurred: Street, Town, State

  • Were MSDS sheets available:

  • Type of Exposure / Material:

  • Other type of exposure:

  • Was area contaminated and / or isolated:

  • HAZMAT crew called:

  • Photographs of exposure area and materials (attached)

  • Photo

  • Now long was employee exposed to hazardous material:

  • Did employee complain of any symptoms prior to exposure:

  • Describe in detail the employee's symptoms after exposure:

  • Has the employee had a history of similar symptoms / complaints:

  • Were there others working in the exposed area:

  • List names of others working in the exposed area:

  • Were environmental studies made available prior to beginning work:

  • Describe in detail what was being done at the time of exposure:

  • Was information made available covering affects of exposure:

  • If yes describe:

Injuries

  • Did injuries occur:

  • Were persons injured transported to medical facility?

  • Mode of transportation:

  • Name of Medical Facility, address, city, state, phone number:

Eye witness information:

  • Name, address, phone cell/home

  • Eye witness description of accident or attached photo:

  • Photo

  • Supervisors description of exposure and any unusual findings or attached photo:

  • Photo

  • Recommendations on corrective action to prevent similar accidents:

  • Safety representative shall provide transportation for the employee to a drug testing facility. (If this is a DOT recordable accident drug and alcohol testing must be done within 2 hours).

  • Supervisors signature :

Heat stroke, Heat exhaustion, Heart attack

Heat Stroke, Heat Exhaustion, Heart Attack

  • Heat Stoke, Heat Exhaustion, Heart Attack

  • Location of incident: Street, Town, State

  • Time employee arrived at work:

  • Time of event:

  • Signs / Symptoms of event:

  • Medical history of heart disease or stroke:

  • Weather factors:

  • Temperature:

  • Specific description and diagram (attached photo)

  • Photo

Injuries

  • Did injury occur:

  • Were persons injured transported to a medical facility?

  • Mode of transportation:

  • Name address of medical facility:

Eye witness information:

  • Name, Address, phone cell/home:

  • Eye witness description of incident or attached photo:

  • Photo:

Supervisors description of accident:

  • What was the employee doing within 2 hours prior to the medical event occurred:

  • What type of work / activities was employee doing at the time of the medical event:

  • Did employee take any leave prior to the medical event:

  • Could a specific event in the course of employment been the cause of the medical event:

  • If, yes describe:

  • We're there any complaints by the employee prior to the medical event:

  • Describe:

  • Any personnel issues employee was talking about prior to the medical event:

  • If yes, describe in detail:

  • Recommendations on corrective action to prevent similar accident:

  • Safety representative shall provide transportation for the employee to a drug testing facility. (if this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).

  • Supervisors signature

Lifting or back injury

Lifting/Back injury

  • Lifting/back injury

  • Date / Time of incident:

  • Location: job site, City, State

  • Specific cause of injury:

  • Specific location on back where injury occurred:

  • Chief complaint of pain:

  • Repetitive activity:

  • Treatment:

  • Treating hospital, address of treating facility, physicians name, phone number:

Incident report:

  • Photographs:

  • Add media

  • Description of scene:

  • Description of working being performed at time of incident:

  • Complain from employee before accident/incident:

  • Complain from employee after accident/incident:

  • Conditions of floor or stairs, if applicable:

  • Description of what employee was lifting:

  • Inspection and type of shoes employee was wearing:

  • Has employee requested time off before this alleged accident:

  • Was ergonomics applied to the job specifics for this employee:

  • Weather factors: (if outdoors)

  • Other factors:

Eye witness information:

  • Name, address, phone cell/home:

  • Eye witness description of incident and diagram or attached photo:

  • Add media

  • Supervisors description of accident/incident and diagram or attached photo:

  • Add media

  • Recommendations: Supervisor

  • Recommendations: employee

  • Recommendations: equipment

  • Recommendations: environment

  • Safety representative shall provide transportation for the employee to a drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).

  • Supervisors signature:

Repetitive Trauma

Repetitive Trauma

  • Repetitive Trauma

  • Date/Time of incident:

  • Location where incident occurred: Job site, Address, State

  • Intersection if applicable:

  • Describe the history of exposure to hazardous activity (business and pleasure):

  • Was an ergonomic assessment performed on the work area prior to the incident:

  • Describe full and complete job description:

  • Had employee requested leave prior to the incident:

  • List any known hobbies of employee:

  • Describe the employees daily routine of job, including but not limited to breaks and lunch:

  • Photographs of incident and injury:

  • Photo

  • Did employee complain of any symptoms prior to accident:

  • Describe in detail the employee's symptoms after incident:

  • When did employee begin to complain of symptoms:

  • Has the employee had a history of similar symptoms/complaints:

  • Does the employee have any other health issues:

  • What are these issues:

  • Does the employee follow the safety policies at all times:

  • Explain concerns:

  • Has the employee ever been written up for violations of the safety policy:

  • Were there other employees working in the area:

  • List name of those working in the area:

Injuries

  • Did injuries occur:

  • Were persons injured transported to a medical facility:

  • Mode of transportation:

  • Name of medical facility, address, city, state, phone number:

Eye witness information:

  • Name, address, phone cell/home:

  • Eye witness description and diagram of accident or attached photo:

  • Photo:

  • Supervisors description of accident and unusual finding including but not limited to all employees or attached photo:

  • Photo:

  • Recommendations on corrective actions to prevent similar accidents:

  • Safety representative shall provide transportation for the employee to a drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).

  • Supervisors signature

Slips and Falls

Slips and Falls

  • Slips and Falls

  • Date/Time of incident:

  • Location where incident occurred, job site, city, state:

  • Describe injury (nature / body part):

  • Treatment:

  • Treatment facility Name, Address, City, State. Physician name and phone number:

Incident report

  • Photographs:

  • Add media

  • Description of scene:

  • Inspection and description of employees shoes:

  • Complaints from employee before the accident/incident:

  • Complaints from employee after the accident/incident:

  • Accident occurred on:

  • Describe:

  • Description of Accident:

  • Weather factors:

  • Temperature:

  • Other factors:

Eye witness information:

  • Name, address, phone cell/home:

  • Eye witness description and diagram of accident/incident or attached photo:

  • Add media

  • Supervisors description and diagram of accident/incident or attached photo:

  • Add media

  • Recommendations: supervisor

  • Recommendations: employee

  • Recommendations: equipment

  • Recommendations: environment

  • Safety representative shall provide transportation for employee to a drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).

  • Supervisors signature

Root Cause

Root Cause Analysis Report

  • Determine root cause: Conduct this investigation with an open mind, and assume the readers know nothing about the accident, workers involved or the accident scene. Focus on the fact, NOT opinion. Provide sufficient details, be clear and concise.

PEOPLE:

  • Job Classification:

  • Employee Training / Certificates:

  • Employee training/certificate

  • Was employee supposed to be in the area?

  • Were tools, materials or equipment misused?

  • Was the correct tool used?

  • Was Personal Protective Equipment used incorrectly, didn't fit properly or was not used?

PROCESS:

  • Describe sequence of steps to perform the task?

  • Photos

  • Was there communication for the task (JSA, daily huddle or toolbox talk)?

  • Is it apparent short cuts ere taken and if so what were they?

  • Were there unrecognizable hazards? If so why were they not recognizable?

  • What Watson policies are there for this instance?

Equipment:

  • Was equipment inspections performed?

  • What is the conditional of the equipment?

  • Any known oddities with the equipment?

  • Was the correct equipment used or was a substituted piece of equipment used in its place?

  • Other equipment factors that may have caused the incident?

Environment:

  • What part, if any did other subcontractors, GC or owner play in this incident?

  • What part did the public or traffic play in this incident?

  • Was weather a factor?

  • Was there adequate space to perform the assigned task?

  • Did the location or positioning of equipment, materials and or employees contribute to this incident?

  • Was the hazard recognized?

  • Were other factors such as noise, illumination and lighting or ventilation a contributing factor?

  • Is the job on schedule?

Attach supporting materials to your report: Photos / diagrams

  • Add media

Background questions to know the answer to?

  • Had this risk been reported before?

  • Have other events occurred at this site?

  • Has this employee been involved in other incidents?

  • Was the problem corrected before? If so by who?

  • Have other incidents occurred with this supervisor?

  • Explain in detail why this incident happened.

  • What initiated this incident.

  • List series of events that led to this incident?

  • What was the last event before the accident?

Incident type?

  • Equipment/vehicles

  • Near miss

  • Occupational injury/illness

  • Property damage

This event was the result of:

  • Policy

  • Communication

  • Process

  • Equipment

  • Training

  • Supervision

  • Employee

  • Subcontractor, GC, Owner, General Public

  • Other: explain

  • Describe the overall root cause results.

Solutions to eliminate, prevent, minimize the reoccurrence of this incident.

The above must be corrected by the following.

Corrective actions must be completed and implemented.

  • At earliest opportunity

  • Within 3 days

  • Before further use

  • Other

  • Explain

Root cause report completed by

  • Signature

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