Accident/Injury Incident Report

• 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, Drawing, or 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 AJ Tutt Becky Winter Bill Dean Bob Bucholz Chris McIntosh Dan Dressing Danielle Lammi Dennis Hasche Derek Boekhoff Dilly Thompson Elliot Kokenge Heath Sorlie Jason Bechler Jenna Anderson Lisa Van Der Brink Mary Pruitt Whitney Seykora Zach Hawkins

  • AJ Tutt
  • Becky Winter
  • Bill Dean
  • Bob Bucholz
  • Chris McIntosh
  • Dan Dressing
  • Danielle Lammi
  • Dennis Hasche
  • Derek Boekhoff
  • Dilly Thompson
  • Elliot Kokenge
  • Heath Sorlie
  • Jason Bechler
  • Jenna Anderson
  • Lisa Van Der Brink
  • Mary Pruitt
  • Whitney Seykora
  • Zach Hawkins

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

  No

  Yes

Witnesses

• 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

• Safety Coordinator:

  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