Title Page
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Incident Title (Dept/EE Name/Incident Type/Date)
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Document Number
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Department/Division
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Site conducted
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Date and Time of Occurrence
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Prepared by
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Location
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Incident type
- Injury
- Environmental Release
- Motor Vehicle Incident
- Fire
- Property Damage
- Occupational Illness
Event Details
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Task or Activity at time of Incident
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Physical or immediate causes of incident
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Immediate Actions Taken
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Description of Incident
Where
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Specific location of Occurrence
Who
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Person(s) Involved
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Relationship of Person Involved
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Supervisor of Person Involved
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Date and Time Shift Began
Witnesses
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Witness
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Relationship of Witness
Internal Reporting
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Reported by
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Date Reported
External Reporting Environmental Release
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Reportable Environmental Release
Environmental Release
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Chemical Name
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Release Source
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Released To
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Quantity Released
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Onsite Area Affected
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Chemical Class
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Quantity Recovered
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Offsite area Affected
Weather Conditions
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Weather Conditions
- Clear
- Rain
- Wind
- Fog
- Sleet
- Hail
- Smog
- Haze
- Snow
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Wind Speed
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Wind Direction
- East
- North
- Northeast
- Northwest
- South
- Southeast
- Southwest
- West
Remediation
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Remediation Required
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DESCRIBE REMEDIATION
Insurance Reporting
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Insurance Group Notified
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CLAIMS HANDLER CONTACT INFORMATION
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INSURANCE CLAIM NUMBER
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Date Reported
Risk Assessment
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Open Risk Matrix
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Consequence
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Likelihood
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Risk Level
Root Cause Analysis
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Root Cause
- Equipment and Tools
- Facilities
- Leadership and Supervision
- Nature of Task
- Personal Factors
- Process Controls
- Work Processes
- Working Conditions
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Equipment and Tools
- Access to equipment limited
- Equipment arrangement or placement
- Equipment guarding / protective controls inadequate
- Equipment isolation difficult
- Equipment labels unclear or missing
- Equipment status unclear
- Proper tools unavailable or inadequate
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Facilities
- Facility Changes
- Facility design limits for application
- Facility equipment design specifications
- Facility equipment shipping and handling
- Preventative or predictive maintenance practices
- Procurement practices
- Quality control practices
- Repeat failure of facility equipment
-
Leadership and Supervision
- Communications ineffective
- Expectations unclear/misunderstood
- Impact of concurrent activities not considered
- Inadequate participation in planning and preparation
- Inconsistent follow-through of expectations
- Roles and Responsibilities unclear
- Trends of past incidents not communicated
- Worker selection process need to be reviewed
-
Nature of Task
- Communication difficult during task
- Complex Task - many variables
- Heavy lifting required to perform
- Routine task - repetitive
- Special required equipment / tools unavailable
- Task changed after starting work
- Task hazards not considered
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Personal Factors
- Changes to task situation not recognized
- Communication methods ineffective
- Knowledge of the task inadequate
- Many variable requiring attention at once
- Skills for the task not verified
- Task not analyzed for hazards
- Time to complete task led to shortcuts
- Worker fatigue/distraction
-
Process Controls
- Alarm messages unclear
- Alarm priorities unclear
- Arrangement of displays is confusing
- Controls operate opposite of normal convention
- Critical display information not obvious
- Display labels unclear or ambiguous
- Early warning indicators inadequate
- Repetitive alarms / messages
- System feedback to user delayed
-
Work Processes
- Communication between groups inadequate
- Established procedure not used / not followed
- Planning process incomplete
- Policies, admin controls not applied
- Procedure not adequate for the situation
- Procedure not available or difficult to use
- Requirement for procedure unclear
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Working Conditions
- Confined working spaces
- Housekeeping conditions
- Lighting levels impacted visibility
- Noise levels impacted communication
- Required protective clothings constrained movement
- Signs or labels missing or improperly located
- Weather condition, temperature or air quality effects
Cost
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Cost Type
- Contract Labor
- Equipment Loss
- Penalties/Fines
- Permit Fee
- Physical Damage
- Production Loss
- Remediation
- Training/Eduction
- Disposal
- Other
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Amount
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Description
Follow Up Responsibilities
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Responsible For Incident Investigation
Follow up Responsibilities
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Responsible for Incident Closure
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Description of Incident
Where
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Specific location of Occurrence
Who
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Person Involved
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Relationship of Person Involved
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Supervisor of Person Involved
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Date and Time Shift Began
Witnesses
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Witness
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Relationship of Witness
Event Details
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Task or Activity at time of Incident
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Object or Substance that directly injured or made person ill
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Physical or immediate causes of incident
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Immediate Actions Taken
External Reporting injury/illness
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Reportable Injury/Illness?
Agency
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Agency
- Coast Guard
- Emergency Response
- Federal Environmental
- Federal Health and Safety
- Federal Human Res/Dev
- Federal Industry Board
- Federal Police
- Local Police
- OSHA
- State/Prov Health and Safety
- State/Prov Health and Safety
- State/Prov Human Res/Dev
- State/Prov Industry Board
- State/Prov Police
- State/TCEQ/RRC Environmental
- Transportation
- Workers Compensation Board
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Agency Contact Info
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External Report Number
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Reported Date
Insurance Reporting
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Insurance Group Notified
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CLAIMS HANDLER CONTACT INFORMATION
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INSURANCE CLAIM NUMBER
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Date Reported
Treatment Provided
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First Aid or Medical Aid?
- First Aid
- Medical Aid
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First Aid Responder
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Description of Treatment Provided
Safe Work Practices
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ALCOHOL TEST PERFORMED?
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Date and Time of Test
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DRUG TEST PERFORMED?
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Date and Time of Test
Classification
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Injury Classification
- Restricted Work
- Lost Work
- Fatality
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Estimated Restricted Days
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Description of restrictions
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First Restricted Day
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Date Returned
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Number of restricted days
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Estimated Lost Days
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First Lost Day
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Date Returned
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Number of Lost work days
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Date of fatality
Injury/Illness Details
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Type of Injury/Illness
- Abrasion
- Amputation
- Bruise
- Chemical Burn
- Chipped Tooth
- Contusion
- Electrical Burn
- Electrocution
- Fracture
- Hearing loss
- Laceration
- Poisoning
- Puncture
- Radiation Burn
- Respiratory Condition
- Skin Disorder
- Sprain
- Thermal Burn
- Other
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Body Part
- Abdomen
- Ankle
- Arm
- Back
- Buttocks
- Cardio System
- Chest/Ribs
- Ear
- Elbow
- Eye
- Face
- Fingers
- Foot/Ankle
- Groin
- Hand
- Hand/Wrist
- Head
- Hip
- Internal Body
- Jaw
- Knee
- Leg
- Leg/Knee/Hip
- Mouth
- Neck
- Nervous System
- Nose
- Pelvis
- Respiratory System
- Shoulder
- Teeth
- Toe
- Trunk
- Wrist
- Other
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Left or right
- Left
- Right
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Accident Type
- Contact with electricity or an electric discharge
- Contact with moving machinery or material being machined
- Drowned or asphyxiated
- Exposed to fire/explosion
- Exposed to, or in contact with, a harmful substance
- Fell from a height
- Hit by a moving vehicle
- Hit by a moving, flying, or falling object
- Hit by something fixed or stationary
- Injured by an animal
- injured while handling, lifting, or carrying
- Injured while working at a computer
- Physically assaulted by a person
- Slipped, tripped, or fell on the same level
- Trapped by something collapsing
- Other
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Accident Agent
- Animal/inspect
- Building/Structures
- Chair/Desk (office furniture)
- Chemical
- Compressed Gas Container
- Container (box, barrel, bag)
- Conveyor (belt/screw)
- Conveyor/Elec. / Hoist
- Drum
- Dust/Fume/Particles
- Electrical Apparatus
- Equipment/Apparatus (Fork Truck)
- Flammables
- Floor
- Fuel (gas, diesel)
- Glass
- Ground/Roadway
- Hand Tool
- Hot Surface
- Ice, Snow, Wind
- Knife
- Ladder/Scaffold
- Machine
- Noise
- Power Tool
- Stairway/Stairs/Ramp
- Tote
- Trash
- Vehicle
- Water/Stream
- Working Surface
- Other
Safe Work Practices
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Was PPE Worn?
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PPE Worn
- Chemical Apron
- Chemical Gloves
- Chemical Goggles/Face Shield
- FR Gloves
- Cotton Gloves
- Fall Protection
- FRC 2112 and CAT 2 Certified
- Fire Retardant Clothing
- Hard Hat
- Hearing Protection
- Impact Goggles/Face Shield
- Leather Gloves
- Neoprene Boots
- Personal Monitor
- Reflective or High Visibility Clothing
- Respirator
- Safety Glasses
- Non FR Raingear
- Raingear meeting ASTM F2733 Certification
- Face Shield
- Safety Shoes
- Steel Toed Boots
- Welding Helmet/Shield
- Other
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Describe PPE Worn
Risk Assessment
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Open Risk Matrix
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Consequence
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Likelihood
-
Risk Level
Root Cause Analysis
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Root Cause
- Equipment and Tools
- Facilities
- Leadership and Supervision
- Nature of Task
- Personal Factors
- Process Controls
- Work Processes
- Working Conditions
-
Equipment and Tools
- Access to equipment limited
- Equipment arrangement or placement
- Equipment guarding / protective controls inadequate
- Equipment isolation difficult
- Equipment labels unclear or missing
- Equipment status unclear
- Proper tools unavailable or inadequate
-
Facilities
- Facility Changes
- Facility design limits for application
- Facility equipment design specifications
- Facility equipment shipping and handling
- Preventative or predictive maintenance practices
- Procurement practices
- Quality control practices
- Repeat failure of facility equipment
-
Leadership and Supervision
- Communications ineffective
- Expectations unclear/misunderstood
- Impact of concurrent activities not considered
- Inadequate participation in planning and preparation
- Inconsistent follow-through of expectations
- Roles and Responsibilities unclear
- Trends of past incidents not communicated
- Worker selection process need to be reviewed
-
Nature of Task
- Communication difficult during task
- Complex Task - many variables
- Heavy lifting required to perform
- Routine task - repetitive
- Special required equipment / tools unavailable
- Task changed after starting work
- Task hazards not considered
-
Personal Factors
- Changes to task situation not recognized
- Communication methods ineffective
- Knowledge of the task inadequate
- Many variable requiring attention at once
- Skills for the task not verified
- Task not analyzed for hazards
- Time to complete task led to shortcuts
- Worker fatigue/distraction
-
Process Controls
- Alarm messages unclear
- Alarm priorities unclear
- Arrangement of displays is confusing
- Controls operate opposite of normal convention
- Critical display information not obvious
- Display labels unclear or ambiguous
- Early warning indicators inadequate
- Repetitive alarms / messages
- System feedback to user delayed
-
Work Processes
- Communication between groups inadequate
- Established procedure not used / not followed
- Planning process incomplete
- Policies, admin controls not applied
- Procedure not adequate for the situation
- Procedure not available or difficult to use
- Requirement for procedure unclear
-
Working Conditions
- Confined working spaces
- Housekeeping conditions
- Lighting levels impacted visibility
- Noise levels impacted communication
- Required protective clothings constrained movement
- Signs or labels missing or improperly located
- Weather condition, temperature or air quality effects
Cost
-
Cost Type
- Contract Labor
- Equipment Loss
- Penalties/Fines
- Permit Fee
- Physical Damage
- Production Loss
- Remediation
- Training/Eduction
- Disposal
- Other
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Amount
-
Description
Follow up Responsibilities
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RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW
Follow up Responsibilities
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Responsible for Incident Closure
-
Description of Incident
Where
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Specific location of Occurrence
Who
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Person Involved
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Relationship of Person Involved
- Employee
- Contractor
- Member of the Public
- Other
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Supervisor of Person Involved
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Date and Time Shift Began
Witnesses
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Witness
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Relationship of Witness
Event Details
-
Task or Activity at time of Incident
-
Physical or immediate causes of incident
-
Immediate Actions Taken
External Reporting Motor Vehicle Incident
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Reportable Motor Vehicle Incident?
Agency
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Agency
- Coast Guard
- Emergency Response
- Federal Environmental
- Federal Health and Safety
- Federal Human Res/Dev
- Federal Industry Board
- Federal Police
- Local Police
- OSHA
- State/Prov Health and Safety
- State/Prov Health and Safety
- State/Prov Human Res/Dev
- State/Prov Industry Board
- State/Prov Police
- State/TCEQ/RRC Environmental
- Transportation
- Workers Compensation Board
-
Agency Contact Info
-
External Report Number
- Coast Guard
- Emergency Response
- Federal Environmental
- Federal Health and Safety
- Federal Human Res/Dev
- Federal Industry Board
- Federal Police
- Local Police
- OSHA
- State/Prov Health and Safety
- State/Prov Health and Safety
- State/Prov Human Res/Dev
- State/Prov Industry Board
- State/Prov Police
- State/TCEQ/RRC Environmental
- Transportation
- Workers Compensation Board
-
Reported Date
- Coast Guard
- Emergency Response
- Federal Environmental
- Federal Health and Safety
- Federal Human Res/Dev
- Federal Industry Board
- Federal Police
- Local Police
- OSHA
- State/Prov Health and Safety
- State/Prov Health and Safety
- State/Prov Human Res/Dev
- State/Prov Industry Board
- State/Prov Police
- State/TCEQ/RRC Environmental
- Transportation
- Workers Compensation Board
Safe Work Practices
-
ALCOHOL TEST PERFORMED?
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Date and Time of Test
-
DRUG TEST PERFORMED?
-
Date and Time of Test
Weather Conditions
-
Weather Conditions
- Clear
- Rain
- Wind
- Fog
- Sleet
- Hail
- Smog
- Haze
- Snow
-
Wind Speed
-
Wind Direction
- East
- North
- Northeast
- Northwest
- South
- Southeast
- Southwest
- West
Motor Vehicle Incident Information
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Physical Cause
- Struck animal
- Struck building
- Struck moving vehcile
- Struck non-moving vehcile
- Struck object
- Struck Person
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Posted Speed Limit
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Road Conditions
- Black ice
- Clear
- Compact snow
- Flooded
- Icy
- Snow covered
- Wet
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Road Type
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Visability
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Police Report Filed
Vehicle Information
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Driving Activity
- Backing Up
- Parallel parking
- Parking
- Parked
- Pulling forward
- Stalled during shifting
- Turning left
- Turning right
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Driving Speed
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Vehicle Ownership
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Vehicle ID Number
-
Vehicle Plate #
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Drivers Liscense Number
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Duty Status
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Condition of Driver
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Driver wearing their seatbelt?
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Citation Issued?
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Driver Information
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Number of Passengers Injured:
-
Number of Passengers:
-
Contact #:
Risk Assessment
-
Open Risk Matrix
-
Consequence
-
Likelihood
-
Risk Level
Root Cause Analysis
-
Root Cause
- Equipment and Tools
- Facilities
- Leadership and Supervision
- Nature of Task
- Personal Factors
- Process Controls
- Work Processes
- Working Conditions
-
Equipment and Tools
- Access to equipment limited
- Equipment arrangement or placement
- Equipment guarding / protective controls inadequate
- Equipment isolation difficult
- Equipment labels unclear or missing
- Equipment status unclear
- Proper tools unavailable or inadequate
-
Facilities
- Facility Changes
- Facility design limits for application
- Facility equipment design specifications
- Facility equipment shipping and handling
- Preventative or predictive maintenance practices
- Procurement practices
- Quality control practices
- Repeat failure of facility equipment
-
Leadership and Supervision
- Communications ineffective
- Expectations unclear/misunderstood
- Impact of concurrent activities not considered
- Inadequate participation in planning and preparation
- Inconsistent follow-through of expectations
- Roles and Responsibilities unclear
- Trends of past incidents not communicated
- Worker selection process need to be reviewed
-
Nature of Task
- Communication difficult during task
- Complex Task - many variables
- Heavy lifting required to perform
- Routine task - repetitive
- Special required equipment / tools unavailable
- Task changed after starting work
- Task hazards not considered
-
Personal Factors
- Changes to task situation not recognized
- Communication methods ineffective
- Knowledge of the task inadequate
- Many variable requiring attention at once
- Skills for the task not verified
- Task not analyzed for hazards
- Time to complete task led to shortcuts
- Worker fatigue/distraction
-
Process Controls
- Alarm messages unclear
- Alarm priorities unclear
- Arrangement of displays is confusing
- Controls operate opposite of normal convention
- Critical display information not obvious
- Display labels unclear or ambiguous
- Early warning indicators inadequate
- Repetitive alarms / messages
- System feedback to user delayed
-
Work Processes
- Communication between groups inadequate
- Established procedure not used / not followed
- Planning process incomplete
- Policies, admin controls not applied
- Procedure not adequate for the situation
- Procedure not available or difficult to use
- Requirement for procedure unclear
-
Working Conditions
- Confined working spaces
- Housekeeping conditions
- Lighting levels impacted visibility
- Noise levels impacted communication
- Required protective clothings constrained movement
- Signs or labels missing or improperly located
- Weather condition, temperature or air quality effects
Insurance Reporting
-
Insurance Group Notified
-
CLAIMS HANDLER CONTACT INFORMATION
-
INSURANCE CLAIM NUMBER
-
Date Reported
Cost
-
Cost Type
- Contract Labor
- Equipment Loss
- Penalties/Fines
- Permit Fee
- Physical Damage
- Production Loss
- Remediation
- Training/Eduction
- Disposal
- Other
-
Amount
-
Description
Follow up Responsibilities
-
RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW
Follow up Responsibilities
-
Responsible for Incident Closure
-
Description of Incident
Where
-
Specific location of Occurrence
Who
-
Person Involved
-
Relationship of Person Involved
-
Supervisor of Person Involved
-
Date and Time Shift Began
Witnesses
-
Witness
-
Relationship of Witness
Event Details
-
Task or Activity at time of Incident
-
Physical or immediate causes of incident
-
Immediate Actions Taken
External Reporting Fire/Explosion
-
External Reporting Fire/Explosion ?
Agency
-
Agency
- Coast Guard
- Emergency Response
- Federal Environmental
- Federal Health and Safety
- Federal Human Res/Dev
- Federal Industry Board
- Federal Police
- Local Police
- OSHA
- State/Prov Health and Safety
- State/Prov Health and Safety
- State/Prov Human Res/Dev
- State/Prov Industry Board
- State/Prov Police
- State/TCEQ/RRC Environmental
- Transportation
- Workers Compensation Board
-
Agency Contact Info
-
External Report Number
- Coast Guard
- Emergency Response
- Federal Environmental
- Federal Health and Safety
- Federal Human Res/Dev
- Federal Industry Board
- Federal Police
- Local Police
- OSHA
- State/Prov Health and Safety
- State/Prov Health and Safety
- State/Prov Human Res/Dev
- State/Prov Industry Board
- State/Prov Police
- State/TCEQ/RRC Environmental
- Transportation
- Workers Compensation Board
-
Reported Date
- Coast Guard
- Emergency Response
- Federal Environmental
- Federal Health and Safety
- Federal Human Res/Dev
- Federal Industry Board
- Federal Police
- Local Police
- OSHA
- State/Prov Health and Safety
- State/Prov Health and Safety
- State/Prov Human Res/Dev
- State/Prov Industry Board
- State/Prov Police
- State/TCEQ/RRC Environmental
- Transportation
- Workers Compensation Board
Insurance Reporting
-
Insurance Group Notified
-
CLAIMS HANDLER CONTACT INFORMATION
-
INSURANCE CLAIM NUMBER
-
Date Reported
Fire Information
-
Ignition Source
- Electrical Equipment
- Electrical Welding Arc
- Exposed Incandescent material
- Grass/Pasture/Vegetation
- Hot Flare Shroud Pieces
- Hot Surfaces
- Lightning strike
- Mechanical Equipment
- Mechanical Spark
- Naked Flame
- Oil or Fluids in Flare Line
- Other
- Static Electricity Spark
-
Extinguishing Method
- Fire Hose
- Fire Sprinkler System
- Portable Fire Extinguisher
-
Time to Extinguish Fire
Risk Assessment
-
Open Risk Matrix
-
Consequence
-
Likelihood
-
Risk Level
Root Cause Analysis
-
Root Cause
- Equipment and Tools
- Facilities
- Leadership and Supervision
- Nature of Task
- Personal Factors
- Process Controls
- Work Processes
- Working Conditions
-
Equipment and Tools
- Access to equipment limited
- Equipment arrangement or placement
- Equipment guarding / protective controls inadequate
- Equipment isolation difficult
- Equipment labels unclear or missing
- Equipment status unclear
- Proper tools unavailable or inadequate
-
Facilities
- Facility Changes
- Facility design limits for application
- Facility equipment design specifications
- Facility equipment shipping and handling
- Preventative or predictive maintenance practices
- Procurement practices
- Quality control practices
- Repeat failure of facility equipment
-
Leadership and Supervision
- Communications ineffective
- Expectations unclear/misunderstood
- Impact of concurrent activities not considered
- Inadequate participation in planning and preparation
- Inconsistent follow-through of expectations
- Roles and Responsibilities unclear
- Trends of past incidents not communicated
- Worker selection process need to be reviewed
-
Nature of Task
- Communication difficult during task
- Complex Task - many variables
- Heavy lifting required to perform
- Routine task - repetitive
- Special required equipment / tools unavailable
- Task changed after starting work
- Task hazards not considered
-
Personal Factors
- Changes to task situation not recognized
- Communication methods ineffective
- Knowledge of the task inadequate
- Many variable requiring attention at once
- Skills for the task not verified
- Task not analyzed for hazards
- Time to complete task led to shortcuts
- Worker fatigue/distraction
-
Process Controls
- Alarm messages unclear
- Alarm priorities unclear
- Arrangement of displays is confusing
- Controls operate opposite of normal convention
- Critical display information not obvious
- Display labels unclear or ambiguous
- Early warning indicators inadequate
- Repetitive alarms / messages
- System feedback to user delayed
-
Work Processes
- Communication between groups inadequate
- Established procedure not used / not followed
- Planning process incomplete
- Policies, admin controls not applied
- Procedure not adequate for the situation
- Procedure not available or difficult to use
- Requirement for procedure unclear
-
Working Conditions
- Confined working spaces
- Housekeeping conditions
- Lighting levels impacted visibility
- Noise levels impacted communication
- Required protective clothings constrained movement
- Signs or labels missing or improperly located
- Weather condition, temperature or air quality effects
Cost
-
Cost Type
- Contract Labor
- Equipment Loss
- Penalties/Fines
- Permit Fee
- Physical Damage
- Production Loss
- Remediation
- Training/Eduction
- Disposal
- Other
-
Amount
-
Description
Follow up Responsibilities
-
RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW
Follow up Responsibilities
-
Responsible for Incident Closure
-
Description of Incident
Where
-
Specific location of Occurrence
Who
-
Person Involved
-
Relationship of Person Involved
-
Supervisor of Person Involved
-
Date and Time Shift Began
Witnesses
-
Witness
-
Relationship of Witness
Event Details
-
Task or Activity at time of Incident
-
Physical or immediate causes of incident
-
Immediate Actions Taken
Insurance Reporting
-
Insurance Group Notified
-
CLAIMS HANDLER CONTACT INFORMATION
-
INSURANCE CLAIM NUMBER
-
Date Reported
Risk Assessment
-
Open Risk Matrix
-
Consequence
-
Likelihood
-
Risk Level
Root Cause Analysis
-
Root Cause
- Equipment and Tools
- Facilities
- Leadership and Supervision
- Nature of Task
- Personal Factors
- Process Controls
- Work Processes
- Working Conditions
-
Equipment and Tools
- Access to equipment limited
- Equipment arrangement or placement
- Equipment guarding / protective controls inadequate
- Equipment isolation difficult
- Equipment labels unclear or missing
- Equipment status unclear
- Proper tools unavailable or inadequate
-
Facilities
- Facility Changes
- Facility design limits for application
- Facility equipment design specifications
- Facility equipment shipping and handling
- Preventative or predictive maintenance practices
- Procurement practices
- Quality control practices
- Repeat failure of facility equipment
-
Leadership and Supervision
- Communications ineffective
- Expectations unclear/misunderstood
- Impact of concurrent activities not considered
- Inadequate participation in planning and preparation
- Inconsistent follow-through of expectations
- Roles and Responsibilities unclear
- Trends of past incidents not communicated
- Worker selection process need to be reviewed
-
Nature of Task
- Communication difficult during task
- Complex Task - many variables
- Heavy lifting required to perform
- Routine task - repetitive
- Special required equipment / tools unavailable
- Task changed after starting work
- Task hazards not considered
-
Personal Factors
- Changes to task situation not recognized
- Communication methods ineffective
- Knowledge of the task inadequate
- Many variable requiring attention at once
- Skills for the task not verified
- Task not analyzed for hazards
- Time to complete task led to shortcuts
- Worker fatigue/distraction
-
Process Controls
- Alarm messages unclear
- Alarm priorities unclear
- Arrangement of displays is confusing
- Controls operate opposite of normal convention
- Critical display information not obvious
- Display labels unclear or ambiguous
- Early warning indicators inadequate
- Repetitive alarms / messages
- System feedback to user delayed
-
Work Processes
- Communication between groups inadequate
- Established procedure not used / not followed
- Planning process incomplete
- Policies, admin controls not applied
- Procedure not adequate for the situation
- Procedure not available or difficult to use
- Requirement for procedure unclear
-
Working Conditions
- Confined working spaces
- Housekeeping conditions
- Lighting levels impacted visibility
- Noise levels impacted communication
- Required protective clothings constrained movement
- Signs or labels missing or improperly located
- Weather condition, temperature or air quality effects
Cost
-
Cost Type
- Contract Labor
- Equipment Loss
- Penalties/Fines
- Permit Fee
- Physical Damage
- Production Loss
- Remediation
- Training/Eduction
- Disposal
- Other
-
Amount
-
Description
Follow up Responsibilities
-
RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW
Follow up Responsibilities
-
Responsible for Incident Closure
-
Description of Incident
Where
-
Specific location of Occurrence
Who
-
Person Involved
-
Relationship of Person Involved
-
Supervisor of Person Involved
-
Date and Time Shift Began
Witnesses
-
Witness
-
Relationship of Witness
- Employee
- Contractor
- Member of the Public
- Other
Event Details
-
Task or Activity at time of Incident
-
Object or Substance that directly injured or made person ill
-
Physical or immediate causes of incident
-
Immediate Actions Taken
External Reporting injury/illness
-
Reportable Injury/Illness?
Agency
-
Agency
- Coast Guard
- Emergency Response
- Federal Environmental
- Federal Health and Safety
- Federal Human Res/Dev
- Federal Industry Board
- Federal Police
- Local Police
- OSHA
- State/Prov Health and Safety
- State/Prov Health and Safety
- State/Prov Human Res/Dev
- State/Prov Industry Board
- State/Prov Police
- State/TCEQ/RRC Environmental
- Transportation
- Workers Compensation Board
-
Agency Contact Info
-
External Report Number
- Coast Guard
- Emergency Response
- Federal Environmental
- Federal Health and Safety
- Federal Human Res/Dev
- Federal Industry Board
- Federal Police
- Local Police
- OSHA
- State/Prov Health and Safety
- State/Prov Health and Safety
- State/Prov Human Res/Dev
- State/Prov Industry Board
- State/Prov Police
- State/TCEQ/RRC Environmental
- Transportation
- Workers Compensation Board
-
Reported Date
- Coast Guard
- Emergency Response
- Federal Environmental
- Federal Health and Safety
- Federal Human Res/Dev
- Federal Industry Board
- Federal Police
- Local Police
- OSHA
- State/Prov Health and Safety
- State/Prov Health and Safety
- State/Prov Human Res/Dev
- State/Prov Industry Board
- State/Prov Police
- State/TCEQ/RRC Environmental
- Transportation
- Workers Compensation Board
Insurance Reporting
-
Insurance Group Notified
-
CLAIMS HANDLER CONTACT INFORMATION
-
INSURANCE CLAIM NUMBER
-
Date Reported
Treatment Provided
-
First Aid or Medical Aid?
- First Aid
- Medical Aid
-
First Aid Responder
-
Description of Treatment Provided
Classification
-
Injury Classification
- Restricted Work
- Lost Work
- Fatality
-
Estimated Restricted Days
-
Description of restrictions
-
First Restricted Day
-
Date Returned
-
Number of restricted days
-
Estimated Lost Days
-
First Lost Day
-
Date Returned
-
Number of Lost work days
-
Date of fatality
Injury/Illness Details
-
Type of Injury/Illness
- Abrasion
- Amputation
- Bruise
- Chemical Burn
- Chipped Tooth
- Contusion
- Electrical Burn
- Electrocution
- Fracture
- Hearing loss
- Laceration
- Poisoning
- Puncture
- Radiation Burn
- Respiratory Condition
- Skin Disorder
- Sprain
- Thermal Burn
- Other
-
Body Part
- Abdomen
- Ankle
- Arm
- Back
- Buttocks
- Cardio System
- Chest/Ribs
- Ear
- Elbow
- Eye
- Face
- Fingers
- Foot/Ankle
- Groin
- Hand
- Hand/Wrist
- Head
- Hip
- Internal Body
- Jaw
- Knee
- Leg
- Leg/Knee/Hip
- Mouth
- Neck
- Nervous System
- Nose
- Pelvis
- Respiratory System
- Shoulder
- Teeth
- Toe
- Trunk
- Wrist
- Other
-
Left or right
- Left
- Right
-
Accident Type
- Contact with electricity or an electric discharge
- Contact with moving machinery or material being machined
- Drowned or asphyxiated
- Exposed to fire/explosion
- Exposed to, or in contact with, a harmful substance
- Fell from a height
- Hit by a moving vehicle
- Hit by a moving, flying, or falling object
- Hit by something fixed or stationary
- Injured by an animal
- injured while handling, lifting, or carrying
- Injured while working at a computer
- Physically assaulted by a person
- Slipped, tripped, or fell on the same level
- Trapped by something collapsing
- Other
-
Accident Agent
- Animal/inspect
- Building/Structures
- Chair/Desk (office furniture)
- Chemical
- Compressed Gas Container
- Container (box, barrel, bag)
- Conveyor (belt/screw)
- Conveyor/Elec. / Hoist
- Drum
- Dust/Fume/Particles
- Electrical Apparatus
- Equipment/Apparatus (Fork Truck)
- Flammables
- Floor
- Fuel (gas, diesel)
- Glass
- Ground/Roadway
- Hand Tool
- Hot Surface
- Ice, Snow, Wind
- Knife
- Ladder/Scaffold
- Machine
- Noise
- Power Tool
- Stairway/Stairs/Ramp
- Tote
- Trash
- Vehicle
- Water/Stream
- Working Surface
- Other
Safe Work Practices
-
Was PPE Worn?
-
PPE Worn
- Chemical Apron
- Chemical Gloves
- Chemical Goggles/Face Shield
- FR Gloves
- Cotton Gloves
- Fall Protection
- FRC 2112 and CAT 2 Certified
- Fire Retardant Clothing
- Hard Hat
- Hearing Protection
- Impact Goggles/Face Shield
- Leather Gloves
- Neoprene Boots
- Personal Monitor
- Reflective or High Visibility Clothing
- Respirator
- Safety Glasses
- Non FR Raingear
- Raingear meeting ASTM F2733 Certification
- Face Shield
- Safety Shoes
- Steel Toed Boots
- Welding Helmet/Shield
- Other
-
Describe PPE Worn
Safe Work Practices
-
ALCOHOL TEST PERFORMED?
-
Date and Time of Test
-
DRUG TEST PERFORMED?
-
Date and Time of Test
Risk Assessment
-
Open Risk Matrix
-
Consequence
-
Likelihood
-
Risk Level
Root Cause Analysis
-
Root Cause
- Equipment and Tools
- Facilities
- Leadership and Supervision
- Nature of Task
- Personal Factors
- Process Controls
- Work Processes
- Working Conditions
-
Equipment and Tools
- Access to equipment limited
- Equipment arrangement or placement
- Equipment guarding / protective controls inadequate
- Equipment isolation difficult
- Equipment labels unclear or missing
- Equipment status unclear
- Proper tools unavailable or inadequate
-
Facilities
- Facility Changes
- Facility design limits for application
- Facility equipment design specifications
- Facility equipment shipping and handling
- Preventative or predictive maintenance practices
- Procurement practices
- Quality control practices
- Repeat failure of facility equipment
-
Leadership and Supervision
- Communications ineffective
- Expectations unclear/misunderstood
- Impact of concurrent activities not considered
- Inadequate participation in planning and preparation
- Inconsistent follow-through of expectations
- Roles and Responsibilities unclear
- Trends of past incidents not communicated
- Worker selection process need to be reviewed
-
Nature of Task
- Communication difficult during task
- Complex Task - many variables
- Heavy lifting required to perform
- Routine task - repetitive
- Special required equipment / tools unavailable
- Task changed after starting work
- Task hazards not considered
-
Personal Factors
- Changes to task situation not recognized
- Communication methods ineffective
- Knowledge of the task inadequate
- Many variable requiring attention at once
- Skills for the task not verified
- Task not analyzed for hazards
- Time to complete task led to shortcuts
- Worker fatigue/distraction
-
Process Controls
- Alarm messages unclear
- Alarm priorities unclear
- Arrangement of displays is confusing
- Controls operate opposite of normal convention
- Critical display information not obvious
- Display labels unclear or ambiguous
- Early warning indicators inadequate
- Repetitive alarms / messages
- System feedback to user delayed
-
Work Processes
- Communication between groups inadequate
- Established procedure not used / not followed
- Planning process incomplete
- Policies, admin controls not applied
- Procedure not adequate for the situation
- Procedure not available or difficult to use
- Requirement for procedure unclear
-
Working Conditions
- Confined working spaces
- Housekeeping conditions
- Lighting levels impacted visibility
- Noise levels impacted communication
- Required protective clothings constrained movement
- Signs or labels missing or improperly located
- Weather condition, temperature or air quality effects
Cost
-
Cost Type
- Contract Labor
- Equipment Loss
- Penalties/Fines
- Permit Fee
- Physical Damage
- Production Loss
- Remediation
- Training/Eduction
- Disposal
- Other
-
Amount
-
Description
Follow up Responsibilities
-
RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW
Follow up Responsibilities
-
Responsible for Incident Closure
