Information
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Name of Injured - Final Accident Investigation:
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Document No.
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Conducted on
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Prepared by:
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Location (Drop Pin for GPS & Address):
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Personnel on Site Today:
Accident/Incident:
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Investigation date:
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Organization that victim was working for:
- W.C. Spratt, Inc.
- Subcontractor
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Name of Subcontractor:
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Employee name:
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Employee Photo:
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Employee #:
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Date of birth:
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Did the employee die?
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Gender:
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Time and date of injury:
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Will the employee be returning to work?
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Return to work date/or expected date:
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Average hours worked per week:
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Will the employee have any restrictions:
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Please detail what restrictions the employee has:
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Are light duty restrictions available for the injured?
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Date and Time when the employer was notified:
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Does employee speak english:
- Yes
- No
- Unknown
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What language:
- English
- Spanish
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Hire date:
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Did he receive full pay for date of injury:
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Job title:
- Dozer Operator
- Driver
- EX-Operator
- Laborer
- Operator
- Pipe Layer
- Superintendant
- Project Manager
- Foreman
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Supervisor name and phone number:
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Where was the medical treatment first provided?
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Please specify:
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Providers name, address and phone number:
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Anyone else injured:
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Nature of Injured:
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Part of body injured:
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Was the employee doing his regular job:
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Describe who, what, when,where, why and how injury occurred:
Part B. Investigation portion.
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Was the person injured a new hire:
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Which one applies to the accident / incident:
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Total years of experience:
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Incident type:
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Please explain further:
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Severity:
- First Aid
- Recordable
- Lost Time
- Restricted Duty
- Fatality
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Was a pre-job safety briefing (tailgate meeting) held before work began?
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Was employee present:
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What topic was reviewed?
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Was a job hazard analysis completed for the work activity in question?
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Was the hazard identified in the job hazard analysis?
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Describe the work activity in progress at the time of the incident. (What was the employee doing, How did the Incident occur)?
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Describe the incident. (Where was the employee, what was the employee doing, How did the Incident occur)?
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Causes of the incident: (Inadequate PPE, Not paying attention to surroundings, behavior based):
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Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)
Corrective Action:
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What was the immediate action taken to correct the issue (how was this done):
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Who was the responsible party for correcting the issue:
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What date must the corrections be implemented and observed?
Action:
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What is the long term action needed to correct the issue:
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Who was the responsible party for correcting the issue:
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What date must the corrections be implemented and observed?
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Lessons Learned:
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Please provide all attachments that apply: pictures, drawings, training records, statement of employee, statement of witness, or other:
Statement of Employee involved in the accident/incident
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Please provide date of incident,time, phone number and description of the incident according to the employee in their own words:
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Employee Signature (If Possible):
Witness Information
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Witness Information
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Photo of the witness
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Witness statement in their words:
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Signature:
OSHA Recordable
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Did the injured person require time off work?
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Has an injury or illness occurred? (If no then it is not recordable).
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Is the injury/illness work-related? An injury or illness is work-related if an event or exposure in the work environment caused or contributed to the injury or illness, or significantly aggravated a pre-existing condition. (If no then it is not recordable).
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Is the injury or illness a new case? Consider an injury or illness a “new case” if the employee has not previously experienced a recorded injury or illness of the same type that affects the same part of the body, or the employee previously experienced a recorded injury or illness of the same type that affected the same part of body but had recovered completely (all signs and symptoms had disappeared) from the previous injury or illness and an event or exposure in the work environment caused the signs or symptoms to reappear. (If no then it is not recordable but we must update the previously recorded entry (contact Safety Manager for OSHA 300 log update).
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Does the injury or illness meet the general criteria for recordable cases? (If the answer is yes to any part of #4 than it is considered recordable, if no then it is not recordable).<br>- Death<br>- Days away from work<br>- Restricted work activity<br>- Transfer to another job<br>- Medical treatment beyond first aid<br>- Loss of consciousness<br>- Significant injury or illness diagnosed by a primary care physician<br>- A needle stick injury or a cut from a sharp object<br>- Exposure to blood or other bodily fluids<br>- Medical removal under the medical surveillance requirements of an OSHA rule, unless it is voluntary medical removal below the removal levels required by a rule<br>- Work-related standard threshold shift in hearing in one or both ears<br>
Report Completed By Safety Manager:
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Signature of Safety Manager:
