Decostar Industries Significant Injury or Event Reporting Form Rev. 1

• Site conducted

  Select

• Form type

  Select Significant Injury or Event Reporting Form

  • Significant Injury or Event Reporting Form

• Accident investigation form initiated

  Date

• Name of primary person involved in accident

• Affected site

  Decostar

  DSC

  GSC

  GMC

  GDC

• Notify Accident

  Notify Accident

• Notify Accident

  Notify Accident

• Notify Accident

  Notify Accident

• Notify Accident

  Notify Accident

• Notify Accident

  Notify Accident

Investigation Team - Fill out information required Information

• One of the following individuals must be notified immediately and this form completed within
  24 hours of the accident and given to:
  Mark Ferguson, Manager, Health & Safety Compliance Programs, Magna International
  (416.302.3510; Mark.Ferguson@magna.com)
  Mark Filak, Director of Labor Relations (U.S.) & Senior HR Legal Counsel,
  Magna International (248.982.6407; Mark.Filak@magna.com)
  Jeff Henkin, Claims Manager (US), Magna International
  (248.797.2429; Jeffrey.Henkin@magna.com)
  Chris Van Wert, Senior Occupational Health & Safety Specialist – U.S, Magna International
  (248.761.8945; Chris.VanWert@magna.com)
  Matt Stauffer, Occupational Health & Safety Specialist – U.S., Magna International
  (864.373.3113; Matthew.Stauffer@magna.com)

• Team must immediately contact OSHA:
  Mandatory OSHA Reporting to Federal/State OSHA Notified at 1-800-321-6742

• Type of Injury

  Select Accident Resulting in Death Accident Resulting in Loss of Consciousness Event that Place Life in Jeopardy Accident Resulting in Fracture to Arm or Leg Accident Resulting in Loss of Sight in Eye Accident Resulting in Hospital Stay for 1 or More Nights Outbreak of Infectious Disease Substantial Loss of Blood Major Burn to Major Part of Body Accident Resulting in Amputation

  • Accident Resulting in Death
  • Accident Resulting in Loss of Consciousness
  • Event that Place Life in Jeopardy
  • Accident Resulting in Fracture to Arm or Leg
  • Accident Resulting in Loss of Sight in Eye
  • Accident Resulting in Hospital Stay for 1 or More Nights
  • Outbreak of Infectious Disease
  • Substantial Loss of Blood
  • Major Burn to Major Part of Body
  • Accident Resulting in Amputation

• Employee Name (First and Last)

• Date and time of accident

  Date

• Date of Hire

  Date

• Description of Accident and Where Occurred (Be Specific)

• Take photographs of accident

  Media

• Extent of Injury

• Was Employee Hospitalized?

  Yes

  No

• Identify Hospital

• Was Surgery Performed Due to Injury?

  Yes

  No

• Identify Type of Surgery or Procedure

• Was Gallagher Basset Contacted?

  Yes

  No

• Date GB was Contacted

  Date

Health and Safety / Management Representative - Fill out information required

• Provide statement of incident/accident

• Describe what happened

Identify The Following Causes

• 1. Write down the specific problem. Writing the issue helps you formalize the problem and describe it completely. It also helps a team focus on the same problem
  2. Ask Why the problem happens and write the answer down below the problem
  3. Identify the Basic Cause, Underlying Cause, and Root Cause

• Why?

• Basic Cause?

• Underlying Cause?

• Root Cause?

• Department Manager Signature

  Sign

• Safety Signature

  Sign

• General Manager Signature

  Sign