• Type of Incident?

Basic Information

  • Name

  • Department

  • Supervisor

  • Date & Time of incident

  • Date & Time Reported

  • 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:

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?

  • Photo, Drawing, or Both?

  • Add media

  • Add drawing

  • Add media

  • Add drawing

First Aid

  • Was on-site first aid treatment required?

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

  • Who?

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

Witnesses

  • Did anyone see the incident happen?

  • List names:

  • The above named witness' state that:

Safety Procedures/Personal Protective Equipment required at time of incident

  • PPE required?

  • Was it used?

  • Explain:

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

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

  • Was it used?

  • Explain:

Cause and prevention

  • What things helped cause this incident?

  • 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:

  • Supervisor:

  • Safety Coordinator:

  • Number of others involved in the investigation?

  • Investigation Team Member:

  • Investigation Team Member:

  • Investigation Team Member:

  • Investigation Team Member:

  • Investigation Team Member:

  • Investigation Team Member:

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