CBIZ BP Loss Control - Accident & Illness Investigation Report

Information

Audit Title
Document No.
Client / Site
Conducted on
Prepared by
Location
Personnel

1.0 - Employer Information

1.1 - Date:
1.2 - Company Name:
1.3 - Completed by:
1.4 - Job Title:
1.5 - Phone Number:
1.6 - Mailing Address:
1.7 - Secondary Employer Company Name:
1.8 - Secondary Employer Contact Name:
1.9 - Secondary Employer Contact Person's Job Title:
1.10 - Phone Number:
1.11 - Mailing Address:

2.0 - Employee Information

2.1 - Full Name:
2.2 - Job Title:
2.2 - Hire Date:
2.3 - Employee Number:
2.3 - Home Address:
2.4 - Birthdate:
2.5 - Gender:

3.0 - Health Care Provider Information

3.1 - Employee Transported by:
3.2 - Facility Name:
3.3 - Street Address:
3.4 - Was Employee Treated in Emergency Room:
3.5 - Was Employee Hospitalized Overnight or In-Patient:
3.6 - If Yes, Length of Stay:

4.0 - Incident Information

4.1 - Date and Time of Incident:
4.2 - Time Employee Began Work:
4.3 - Date of Initial Injury/Illnesses Diagnosis:
4.4 - Number of Days Away From Work:
4.5 - Number of Days of Restricted Work Activity:
4.6 - Type of Injury:
- Amputation
- Chemical Burns
- Deep Tissue Lacerations
- Electrical Burns
- Fatality
- Fracture
- Hospitalization
- Loss of an Eye
- Permanent Disfigurement
- Puncture
- Thermal Burns
4.7 - If this incident was a fatality, date of death
4.8 - Note: If a fatality occurred or more than 1 employees was hospitalized, OSHA must be verbally notified within 8 hours.
4.9 - Note: If a permanent disfigurement occurred, OSHA must be verbally notified within 8 hours.
4.10 - Did incident occur on employer's premises?
4.11 - If yes, where on premises did the incident occur?
4.12 - If no, location of incident?
4.13 - What was the employee doing just before the incident occurred? (Be as specific as possible. If the employee was using tools, equipment, or materials, name them and specify what the employee was doing with them). Example: "climbing a ladder while carrying painting materials", "daily computer entry"
Add media
4.14 - Explain how the incident occurred. List the events that resulted in the injury or illness, what happened, how it happened, and name objects and how they were involved.
Add media
4.15 - Describe the injury/illness. Indicate the part of the body that was affected and how it was affected.
4.16 - Name the object or substance that directly injured the employee. Example: concrete floor
Add media

5.0 - Witness information

Were There Any Witnesses?

Witness Name:
Address:
Phone:
Witness Statement:
Witness Signature:

6.0 - Accident Investigation:

6.1 - Was PPE required for this task?
6.2 - Was equipment adequately guarded? If no, describe deficiency?
6.3 - Has employee received task specific training prior to job assignment?
6.4 - Who completed training:
6.5 - What was the duration of the training:
6.6 - Was training adequate?
6.7 - Was lock out/tag out necessary?
6.8 - Were any safety mechanisms bypassed?
6.9 - Has the cause of the injury/illness been corrected?
6.10 - Date
6.11 - Describe future action to be taken, including preventative measures to ensure that such injury/illness does not occur again.
Add media
6.12 - Completed by
6.13 - Approved by:
6.14 - Supervisor on duty:

7.0 - Accident Investigation - Employee Interview

7.1 - Department
7.2 - Supervisor
7.3 - Accident Location
7.4 - Accident Date & Time
7.5 - Report Date & Time
7.6 - The employee involved in the accident - Briefly explain in your own words the circumstances that led to the accident event. Also include your involvement in the accident. Your comments are important to help determine the causes of the accident and correct any unsafe conditions. Thank you.
7.7 - How often is task performed that cause the injury?
7.8 - I have written the above statement and certify that it is true to the best of my knowledge.
7.9 - Employee Signature

8.0 - Conclusion / Root Cause:

8.1 - Enter Conclusions:

9.0 - Corrective Action Required:

9.1 - Corrective Action:

10.0 - Pictures & Drawings:

10.1 - Enter all corrective preventative actions that will be implemented:
10.2 - Take pictures of injury/accident including body part(s), location, equipment, tools, etc.
10.3 - Diagram:
10.4 - Investigator Signature