Accident Investigation Reports

• Document No.

• Watson Electric Report

  Select Automobile Accident Burn Cut Line Exposure Heat Stroke Heat Exhaustion Heart Attack Lifting Back Injury incident Repetitive trauma incident Slips and Falls

  • Automobile Accident
  • Burn
  • Cut Line
  • Exposure
  • Heat Stroke
  • Heat Exhaustion
  • Heart Attack
  • Lifting Back Injury incident
  • Repetitive trauma incident
  • Slips and Falls

• Conducted on

  Date

• Prepared by

• Accident Date / Time

  Date

• Division:

• Date report complete

  Date

• Employee name

• Last four of Social Security no.:

• Job Title

• Supervisor

• Employee home address

• Employee cell/home phone

• If auto accident:

  yes

  no

• Watson Electric drivers description of accident:

• Immediate drug screen performed

  yes

  no

Automobile Accident

• Auto accident:

  yes

  no

• Location of accident: street, city, state

• Intersection if applicable:

• Type of collision:

  Select Pedestrain Head on Read End Single Car Other

  • Pedestrain
  • Head on
  • Read End
  • Single Car
  • Other

• Photographs of the accident scene:

  yes

  no

• Skid marks made from Watson Electric vehicle:

  yes

  no

• Measurement of skid marks:

• Skid marks made from other parties involved in accident:

  yes

  no

• Measurements of skid marks:

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

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

• Weather factors:

  Select n/a sun rain snow ice sleet wind

  • n/a
  • sun
  • rain
  • snow
  • ice
  • sleet
  • wind

• Which driver was effected by the weather:

  Select Watson Electric Other Party

  • Watson Electric
  • Other Party

• Comments:

Injuries

• Did injuries occur:

  yes

  no

• Names and phone numbers of those injuries:

• Were persons injured transported to a medical facility:

  yes

  no

• Mode of transportation:

  Select EMS Employer Other

  • EMS
  • Employer
  • Other

• 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

  Media

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

• Add media

  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:

  Sign

Burn Incident Report

• Burn incident report

  yes

  no

• Date and time of Burn incident

  Date

• Type of Burn:

  Select Panel Box Transmission Other

  • Panel Box
  • Transmission
  • Other

• 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:

  yes

  no

• Glove test date:

  Date

• List protective gear worn by employee:

• We're rubber blankets used:

  yes

  no

• Rubber blanket test date:

  Date

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

  yes

  no

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

  yes

  no

• Photographs of area where incident occurred:

  yes

  no

• Photo

  Media

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

Injuries

• Did injuries occur?

  yes

  no

• Did employee lose consciousness?

  yes

  no

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

• Were persons injured transported to a medical facility:

  yes

  no

• Mode of transportation:

  EMS

  Employer

  Other

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

Eye witness information:

• Name address, phone cell/home

• Eyewitness description of accident or attached photo:

• Photo

  Media

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

• Photo

  Media

• 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

  Sign

Cut Line Incident

• Cut line incident

  yes

  no

• Date / Time line was cut:

  Date

• Type of line cut:

• Location of cut line street, town, state

• Intersection if applicable:

• Was cut line active:

  yes

  no

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

  yes

  no

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

  yes

  no

• Photo

  Media

Locate information

• Locate ticket number:

• Name of person who called for the locate ticket:

• Was update required for locate ticket?

  yes

  no

• Date of up dated locate ticket:

  Date

• 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?

  yes

  no

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

• Were injured people transported to a medical facility:

  yes

  no

• Mode of transportation:

  yes

  no

  N/A

• 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

  Media

• 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

  Media

• 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:

  Sign

Exposure Incident

• Exposure incident

  yes

  no

• Date / Time of exposure:

  Date

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

• Were MSDS sheets available:

  yes

  no

• Type of Exposure / Material:

  Select Asbestos Silica Lead Arsenic Contaimination Other

  • Asbestos
  • Silica
  • Lead
  • Arsenic Contaimination
  • Other

• Other type of exposure:

• Was area contaminated and / or isolated:

  yes

  no

• HAZMAT crew called:

  yes

  no

• Photographs of exposure area and materials (attached)

  yes

  no

• Photo

  Media

• Now long was employee exposed to hazardous material:

• Did employee complain of any symptoms prior to exposure:

  yes

  no

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

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

  yes

  no

• Were there others working in the exposed area:

  yes

  no

• List names of others working in the exposed area:

• Were environmental studies made available prior to beginning work:

  yes

  no

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

• Was information made available covering affects of exposure:

  yes

  no

• If yes describe:

Injuries

• Did injuries occur:

  yes

  no

• Were persons injured transported to medical facility?

  yes

  no

• Mode of transportation:

  EMS

  Employer

  Other

• 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

  Media

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

• Photo

  Media

• 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 :

  Sign

Heat Stroke, Heat Exhaustion, Heart Attack

• Heat Stoke, Heat Exhaustion, Heart Attack

  yes

  no

• Location of incident: Street, Town, State

• Time employee arrived at work:

  Date

• Time of event:

  Date

• Signs / Symptoms of event:

  Select chest pain nausea vomiting fatigue shortness of breath weakness headache dizziness fainting heavy sweating paleness muscle cramps

  • chest pain
  • nausea
  • vomiting
  • fatigue
  • shortness of breath
  • weakness
  • headache
  • dizziness
  • fainting
  • heavy sweating
  • paleness
  • muscle cramps

• Medical history of heart disease or stroke:

  yes

  no

• Weather factors:

  Select n/a sun rain snow ice sleet wind

  • n/a
  • sun
  • rain
  • snow
  • ice
  • sleet
  • wind

• Temperature:

• Specific description and diagram (attached photo)

• Photo

  Media

Injuries

• Did injury occur:

  yes

  no

• Were persons injured transported to a medical facility?

  yes

  no

• Mode of transportation:

  Select EMS Employer Other

  • EMS
  • Employer
  • Other

• Name address of medical facility:

Eye witness information:

• Name, Address, phone cell/home:

• Eye witness description of incident or attached photo:

• Photo:

  Media

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:

  yes

  no

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

  yes

  no

• If, yes describe:

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

  yes

  no

• Describe:

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

  yes

  no

• 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

  Sign

Lifting/Back injury

• Lifting/back injury

  yes

  no

• Date / Time of incident:

  Date

• Location: job site, City, State

• Specific cause of injury:

• Specific location on back where injury occurred:

• Chief complaint of pain:

• Repetitive activity:

  yes

  no

• Treatment:

  Select none first aid only doctor hospital

  • none
  • first aid only
  • doctor
  • hospital

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

Incident report:

• Photographs:

  yes

  no

• Select scene employee injury shoes cause of injury (object/area)

  • scene
  • employee injury
  • shoes
  • cause of injury (object/area)

• Add media

  Media

• Description of scene:

• 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:

  yes

  no

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

  yes

  no

• Weather factors: (if outdoors)

  Select N/A sunny rain snow ice sleet wind

  • N/A
  • sunny
  • rain
  • snow
  • ice
  • sleet
  • wind

• Other factors:

  Select loose sand unlevel terrain hole condesation

  • loose sand
  • unlevel terrain
  • hole
  • condesation

Eye witness information:

• Name, address, phone cell/home:

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

• Add media

  Media

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

• Add media

  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:

  Sign

Repetitive Trauma

• Repetitive Trauma

  yes

  no

• Date/Time of incident:

  Date

• 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:

  yes

  no

• Describe full and complete job description:

• Had employee requested leave prior to the incident:

  yes

  no

• 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:

  yes

  no

• Photo

  Media

• Did employee complain of any symptoms prior to accident:

  yes

  no

• 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:

  yes

  no

• Does the employee have any other health issues:

  yes

  no

• What are these issues:

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

  yes

  no

• Explain concerns:

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

  yes

  no

• Were there other employees working in the area:

  yes

  no

• List name of those working in the area:

Injuries

• Did injuries occur:

  yes

  no

• Were persons injured transported to a medical facility:

  yes

  no

• Mode of transportation:

  Select EMS Employer Other

  • EMS
  • Employer
  • Other

• 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:

  Media

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

• Photo:

  Media

• 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

  Sign

• Yes

  No

  N/A

Slips and Falls

• Slips and Falls

  yes

  no

• Date/Time of incident:

  Date

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

• Describe injury (nature / body part):

• Treatment:

  Select none first aid only doctor hospital

  • none
  • first aid only
  • doctor
  • hospital

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

Incident report

• Photographs:

  yes

  no

• Select scene employees injuries employees shoes

  • scene
  • employees injuries
  • employees shoes

• Add media

  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:

  Select floor stairs ladder platform other

  • floor
  • stairs
  • ladder
  • platform
  • other

• Describe:

• Description of Accident:

• Weather factors:

  Select N/A sunny rain snow ice sleet wind

  • N/A
  • sunny
  • rain
  • snow
  • ice
  • sleet
  • wind

• Temperature:

• Other factors:

  Select loose sand unlevel terrain hole condesation

  • loose sand
  • unlevel terrain
  • hole
  • condesation

Eye witness information:

• Name, address, phone cell/home:

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

• Add media

  Media

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

• Add media

  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

  Sign