BAPKO Metal Incident/Injury Investigation

• Site conducted

  Select

• Incident/Injury Report

• Location
  Address

• Incident Date and Time

  Date

• Prepared by

General Information

Injured Employee


• Employee Name

Description of Injury/Illness?

• Type of Incident

  Select Fall From Height Struck By Falling Object Electrical Shock Burn Engulfment Impalement Laceration Fracture Foreign Body Muscle Strain/Sprain Struck By Inhalation Exposure Caught Between Line of Fire

  • Fall From Height
  • Struck By Falling Object
  • Electrical Shock
  • Burn
  • Engulfment
  • Impalement
  • Laceration
  • Fracture
  • Foreign Body
  • Muscle Strain/Sprain
  • Struck By
  • Inhalation
  • Exposure
  • Caught Between
  • Line of Fire

• Photo(s) of Incident Site

  Media

• Type of Injury?

  Select Sprain/Strain Fracture Laceration Burn Foreign Body Inhalation Abrasion Contusion Electric Shock Chemical Exposure Thermal Injury Crush

  • Sprain/Strain
  • Fracture
  • Laceration
  • Burn
  • Foreign Body
  • Inhalation
  • Abrasion
  • Contusion
  • Electric Shock
  • Chemical Exposure
  • Thermal Injury
  • Crush

• Part of Body Effected

• Left or Right Side, Front or Back, Top or Bottom

  Select Left Side Right Side Front Side Back Side Top Bottom

  • Left Side
  • Right Side
  • Front Side
  • Back Side
  • Top
  • Bottom

Medical Treatment Information

• What type of medical treatment was required?

  Select First Aid - Onsite Self-Administered First Aid - Onsite Assisted First Aid - Onsite Medical First Aid - Offsite Medical Occupational Clinic Treatment Emergency Room Treatment

  • First Aid - Onsite Self-Administered
  • First Aid - Onsite Assisted
  • First Aid - Onsite Medical
  • First Aid - Offsite Medical
  • Occupational Clinic Treatment
  • Emergency Room Treatment

• Name of Treating Medical Service Provider (if Offsite Medical, Clinic, or ER)

• Name and Address of Clinic or Emergency Room

• Clinic or Hospital Phone Number

Incident Statements

Injured Employee Statement

• Employee Statement (describe incident in own words) What happened? How did it happen?

• Photos of Incident Scene

  Media
Witness Statement

• Witness Statement (describe incident) Who, What, Where, When, Why, How. Be Specific, No Opinions.

• Witness Signature

  Sign

Incident Analysis

• Primary Cause?

• Contributing Factors?

Preventative/Corrective Actions

• Immediate Action Required:

• When should this action be completed by?

  Date

• Who Is Responsible to oversee this action?

• Long Term Action Required:

• Who is Responsible to oversee this action?

• When should this action be completed by?

  Date

Accident Investigation Completed by:

• Signature of person completing this investigation.

  Sign

• Investigation completed

  Date

Follow-up Investigation