Title Page
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Site conducted
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Form type
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Type of Incident
- Accident Resulting in Injury
- Accident Resulting in Spill or Leak
- Accident Resulting in First Aid Only
- Accident Resulting in Illness of Employee
- Accident Resulting in Near-Loss
- Accident Resulting in Equipment or Property Damage
- Personal Medical Emergency
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Identify Damaged Equipment/Property
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Identify Body Part Injured
- Head
- Neck
- Shoulder(s)
- Upper Arm-Elbow(s)
- Lower Arm(s)
- Wrist(s)
- Hand(s)
- Chest Area
- Abdominal Area
- Upper Back
- Lower Back
- Hip Area(s)
- Upper Leg(s)
- Knee(s)
- Lower Leg(s)
- Ankle(s)
- Foot-Feet
- Eye(s)
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Name of First Responder who responded
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Was 911 called?
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Who called 911?
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What time was 911 called?
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What time did 911 arrive onsite?
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Was the EMS Procedure properly activated?
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Identify gap(s) in the response
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Is there any room for improvement or lessons learned?
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List the improvement(s) that can be made or lesson(s) learned
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Accident investigation form initiated
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Name of primary person involved in accident
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Affected Department Area
- IMM
- IMM Maintenance
- IMM Tooling
- RIM
- Outside Paint
- Inside Paint
- Paint Maintenance
- Quality and Inspection
- Decostar Logistics
- Engineering
- Office
- Final Assembly
- P33 Assembly
- P33 Maintenance
- Environmental
- DSC Production
- DSC Service / Logistics
- DSC Maintenance
- GSC Production
- GSC Maintenance
- GSC Logistics
- GSC Service
- GMC Production
- GMC Tooling Area
- GMC Maintenance
- GMC Logistics
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Notify Accident
Particulars of Accident (Supervisor to complete)
Area Supervisor - Fill out information required
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Date and time of accident/incident
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Location where the accident occurred (Be specific)
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Accident investigation lead (Supervisor Name)
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H&S contact name
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Time accident was communicated to H&S representative (Contact must be made)
The Employee Involved in Incident (Supervisor to complete)
Supervisor / Management Representative - Fill out information required
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Name of employee(s) involved in incident (First and Last Name)
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Employee job title
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Write down employee statement of incident (Must be a statement from Employee)
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Would you like to take a picture of the employee statement?
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Take picture of the employee statement
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Are there any witnesses to the accident?
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Name of Witness
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Provide a witness statement of the event
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Would you like to take a picture of the witness statement?
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Take a picture of witness statement
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Is the employee a Full-time or Temporary Associate?
- Full Time Hourly Employee
- Full Time Salary Employee
- North Georgia Employee
- PPG
- Hire Dynamics
- Aerotek Employee
- Pride Staffing Employee
- On-site Contractor
- Visitor
- Other
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Describe status of worker
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Was drug screen completed for parties involved in accident? (Drug screens not required for near miss reports)
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Take pictures of all drug screens performed
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Explain why drug screen was not performed
Damaged Property - Including Forklift Incidents and Near Misses (Supervisor to Complete)
Supervisor / Management Representative - Fill out information required
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Did property damage occur within the facility?
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Describe property or material damaged
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Take pictures of damaged property or material
Treatment and Investigation of Accident
Health and Safety / Supervisor - Fill out information required
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Did the injury occur as a result of the incident / accident?
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Describe the type of injury (Supervisor and Safety to Complete)
- First Aid - Report Only
- Injury Requiring Medical Treatment, Hospitalization, or Emergency Medical Treatment
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Name of person giving first aid
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Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
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Specify injured part of body
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Describe Type of Injury
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Take pictures of injury and what contributed to incident
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Type of treatment given
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Does the employee request to seek me medical attention?
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Take Picture of RTW Agreement /Medical Doctor (Chosen by Employee)
Affected Employee Information
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Injured Employee Address
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Injured Employee Date of birth
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Injured Employee Date of Hire
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Hourly Wages
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Injured Employee Phone number
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Employee Marital Status
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Employee Number of Dependents
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Supervisor Name
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Supervisor Phone Number
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Doctor/Hospital (Medical Treatment)
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Describe the Type of Injury
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Take pictures of injury and what contributed to incident
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Describe the Type of First Aid Administered
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OSHA Recordable Injury (Safety to Complete)
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OSHA Recordable Number
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Is OSHA 301 Log Complete
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Is risk assessment completed for job?
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Is risk assessment updated based on recordable injury?
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Is risk assessment completed for job?
The Investigation of Accident (Supervisor and Manager to Complete)
Health and Safety/ Management Representative - Fill out information required
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Provide Supervisor detailed statement of incident/accident
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Describe what happened
Complete Root Cause Analysis
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Answer the following questions to help identify the Root Cause of the Incident
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Was a work guidance or work procedure in place for the job task that caused the incident?
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Take a picture of Work Guidance or Work Procedure
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Assign an action to complete a work procedure for job task
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Is documented training in place for the work guidance or work procedure?
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Take a picture of the signed-off work guidance
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Assign an action to Perform documented training
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Was not wearing PPE (Safety Glasses, Cut Resistant Sleeves/Gloves, etc.) a root cause or contributing factor to the accident?
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Identify missing PPE resulting in the injury and assign corrective action
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Was not following an identified safety procedure a root cause or contributing factor to the incident?
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Identify the safety procedure not followed to result in an incident
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Identify one or more of the following incident states that could have contributed to the incident
- Rushing
- Frustration
- Fatigue
- Complacency
- Eyes not on task
- Mind not on task
- Balance, Traction, and Grip
- Being in the Line of Fire
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Identify the Root Cause of the incident
Corrective / Preventive Actions (Supervisor and Manager)
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Identify Corrective / Preventive Action (Must assign action in I-Auditor)
Additional Corrective / Preventive Actions (Supervisor and Manager)
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Was a corrective action assigned to eliminate or prevent incident from reoccurring?
Accident Review and Sign-off
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Employee Signature
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Additional Signature
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Supervisor Signature
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Department Manager Signature
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JHSC Signature
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Safety Signature
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AGM / General Manager Signature
