Incident Investigation

  • Take as many photos of the scene as possible.

  • Describe, in detail, what occurred. Include the exact task being done and any relevant events leading up to the incident.

  • What type of incident occurred?

  • Date and time of incident

  • Date and time employee began work

  • Name of Injured Employee

  • Department and Shift of Injured Employee

  • Employment Status of Injured Person

  • Describe injury and parts of body affected

  • What object/substance directly injured the employee

  • Injured Employee: State in your own words description of pain/discomfort and location of injury.

  • Pain from scale 1-10

  • Was on-site first aid treatment given?

  • Who administered first aid?

  • What first aid was performed? (ice, bandage, anti-bacterial cream, etc.)

  • Is the employee requesting/in need of medical attention? Tap HERE to enter details.

  • Contact the Safety Manager immediately!

  • Was the employee transported to a local medical establishment?

  • Where was the employee taken for treatment?

  • Investigator: Give accurate description of nature and extent of injury and state your objective findings

  • Investigator: Describe the nature of the damaged equipment. What was damaged? To what extent? Is the equipment operable? Does it pose additional risk to operators in it's current state?

  • What material spilled?

  • Approximately how much material spilled?

  • Did the spill enter a local waterway?

  • Report this incident immediately to the Safety Manager!

  • Were safeguards, safety equipment, or PPE being used prior to the incident?

  • Were safeguards, safety equipment, or PPE provided?

Witness Statement

  • Was there a witness?

  • Witness name

  • Department

  • Date and Time of injury

  • Location where injury occurred.

  • Describe what you saw.

  • Who or what caused the accident/injury?

  • In your opinion what body parts were injured?

  • Was there anything that could have been done to prevent injury?

  • What could have been done?

  • Did anything appear suspicious about the incident?

  • What was suspicious?

  • Witness signature

Root Cause Analysis (5 Why's)

  • Is Root Cause Analyses required?

  • Why?

  • Why
  • Question

  • Answer

  • What is the root cause of this incident?

Immediate Corrective Action

  • Enter corrective actions taken to prevent immediate reoccurrence. Enter suggestions for future corrective actions. Each "Why" in the previous section may result in a corresponding corrective action.

Finalization

  • Injured Workers signature

  • Preparers signature

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