Accident Investigation

• Name

• Conducted on

  Date

• Prepared by

• Type of Incident?

  Accident/Injury

  Near-miss

Basic Information

• Name

• Department

• Supervisor

• Date & Time of incident

  Date

• Date & Time Reported

  Date

• First Reported to Whom?

Injury Information

• Incident type: (contact, fall, strain, caught on/in...)

• Source of hazard: (movement, machine, tool, work surface...)

• Type of injury: (cut, strain, bruise, puncture, burn...)

• Specific body part injured:

• Work activity at the time of incident was:

  Routine

  Non-Routine

Employee's Statement: Exactly What Happened?

• (Pretend you are a slow-motion camera and describe all events in detail. Describe exactly where the incident occurred and what tasks were being performed at the time.)

• The above named employee states that:

• Would you like to add media to the investigation?

  No

  Yes

• Photo or Drawing? Both?

  Photo

  Drawing

  Both

• Add media

  Media

• Add drawing

  Drawing

• Add media

  Media

• Add drawing

  Drawing

First Aid

• Was on-site first aid treatment required?

  No

  Yes

• Did a member of the First Responder Team assist with treatment?

  No

  Yes

• Who?

  Select Alicia K Bill D Bob B Dan D Dennis H Elliot K Jason M Lisa VB Other

  • Alicia K
  • Bill D
  • Bob B
  • Dan D
  • Dennis H
  • Elliot K
  • Jason M
  • Lisa VB
  • Other

• List name(s) for other:

• Did the employee require/request immediate off-site medical treatment?

  No

  Yes

Witnesses

• Were others present at the time of the incident?

  No

  Yes

• List names:

• Did anyone see the incident happen?

  No

  Yes

• List names:

• The above named witness' state that:

Safety Procedures/Personal Protective Equipment required at time of incident

• PPE required?

  Select Closed Toed Shoes Ear Plugs Safety Glasses Respirator Vinyl/Nitrile Gloves Goggles Glove and Sleeve (on opposite arm from glue gun)

  • Closed Toed Shoes
  • Ear Plugs
  • Safety Glasses
  • Respirator
  • Vinyl/Nitrile Gloves
  • Goggles
  • Glove and Sleeve (on opposite arm from glue gun)

• Was it used?

  Yes

  No

• Explain:

• Any Safety Procedures Required? (LOTO, Machine Safe Guards...)

  No

  Yes

• List required safety procedures required at time of the incident:

• Was it used?

  Yes

  No

• Explain:

Cause and prevention

• What things helped cause this incident?

  Select Tool/Equipment Job Procedures Design/Layout of Work Area Time Demands Lack of PPE Lack of Training Other

  • Tool/Equipment
  • Job Procedures
  • Design/Layout of Work Area
  • Time Demands
  • Lack of PPE
  • Lack of Training
  • Other

• List Other(s):

• Explain:

• What will be done to prevent this type of incident from happening again?

• Who is responsible to see this through?

Validation

• The above statements reflect an accurate account of the events surrounding this incident. I understand my treatment rights and responsibilities, including the need to contact Showplace Wood Products immediately following any medical provider visit, any change in condition, or any change in work status.

• Employee:

  Sign

• Supervisor:

  Sign

• Number of others involved in the investigation?

  1

  2

  3

  4

• Investigation Team Member:

  Sign

• Investigation Team Member:

  Sign

• Investigation Team Member:

  Sign

• Investigation Team Member:

  Sign

• Investigation Team Member:

  Sign

• Investigation Team Member:

  Sign

• Investigation Team Member:

  Sign

• Investigation Team Member:

  Sign

• Investigation Team Member:

  Sign

• Investigation Team Member:

  Sign