Information

  • Document No.

  • Short Incident Description

  • Site

  • Conducted on

  • Prepared by

  • Location
  • Investigation Team

Project/Incident Site

Project/Incident Site

  • Job Number and Name of Project Where Incident Occurred

  • Address of Project
  • Manager on Site

  • Phone Number of Manager on Site

  • Current Amount of ECI-Automation Employees OnSite

  • Current schedule of project

  • Is there shift work?

  • Amount on Day Shift

  • Shift Schedule (begin and end)

  • Amount on Night Shift

  • Shift Schedule (begin and end)

  • Is there a safety coordinator assigned to the project

  • Safety Coordinator's name

  • Safety Coordinator's Telephone Number

  • Is there a forman assigned to the project?

  • Forman Name

  • Forman Telephone Number

Incident Investigation

  • What type of incident occurred?

  • Name of Injured Employee

  • Classification/Job Title of Injured Employee

  • Date that Injured Employee was Hired

  • Home Address of Injured Employee
  • Home Telephone Number

  • Mobile Telephone Number

  • Date & Time of incident

  • Date & Time employee began work

  • Describe injury and parts of body affected

  • What object/substance directly injured the employee

  • Injured Employee: State in your own words description of pain/discomfort and location of injury.

  • Pain from scale 1-10

  • Was emergency services notified?

  • Provide reason why

  • Was on-site first aid treatment given?

  • Who administered first aid?

  • What first aid was performed? (ice, bandage, anti-bacterial cream, etc.)

  • Was employee transported to hospital or other medical provider?

  • Name of hospital or medical provider

  • Was employee transported by ambulance?

  • Where did the accident happen and who was involved? Provide a full description of the surroundings of the location and the individuals involved.

  • What was happening at the time of the accident and why was it taking place?

  • What were the events leading up to the accident? Describe the sequence in order and when they took place.

  • Has the employee performed the task before?

  • How many times and what training have they received pertaining to the task?

  • Photograph of certification (if available)

  • Have they received training in order to perform the task?

  • List training employee has received

  • Photograph of certification (if available)

  • List name of supervisor

  • Was there any equipment involved?

  • Describe equipment (provide detail, including serial numbers where available)

  • Were there any tools involved?

  • Describe tools used (provide detail, including serial numbers where available)

  • Has the injured employee ever injured this body part in the past?

  • Photographic Evidence

  • Sketch/diagram of incident scene

  • Add Property/Equipment

  • Item
  • List Property/Equipment Damaged (list model number and serial number if available)

  • Estimated value of equipment or property.

  • Were any ECI-AUTOMATION personnel responsible for the operation of any equipment damaged?

  • Add Name

  • Individual
  • Employee Name

  • Has employee received training in operation of equipment?

  • List training

  • Photograph of certification (if available)

  • Name of employee's supervisor

  • Investigator: Describe the nature of the damaged property or equipment. What was damaged? To what extent? Is the equipment operable? Does it pose additional risk to operators in it's current state?

  • Photographic Evidence

  • Sketch/diagram of incident scene

  • What material spilled?

  • Approximately how much material spilled?

  • Did the spill enter a local waterway?

  • Has this been reported to the EPA?

  • Investigator: Briefly describe how the spill occurred

  • Photographic Evidence

  • Sketch/diagram of incident scene

  • Describe the near-miss incident. Investigator: enter names of people involved with near-miss in the witness area of form.

  • Describe the incident

  • Were safeguards or safety equipment provided?

  • What safeguards or safety equipment was provided?

  • Were safeguards or safety equipment used?

  • What safeguard or which safety equipment was not used?

Witness Statement

  • Add Witness

  • Witness
  • Witness Name

  • Classification/Job Title

  • Telephone Number

  • Date and Time of incident

  • Location where incident occurred.

  • Describe what you saw.

  • Who or what caused the incident?

  • In your opinion what body parts were injured?

  • Was there anything that could have been done to prevent injury?

  • What could have been done?

  • Did anything appear suspicious about the incident?

  • What was suspicious?

  • Witness signature

Root Cause Analysis (5 Why's)

  • Why?

  • Why
  • Question

  • Answer

  • What is the root cause of this incident?

Findings

  • After review of all facts, what was the hazardous condition, unsafe work practice, or other causal factors (procedure, equipment, people and environment) that contributed to the incident?

Corrective Action

  • What is recommended to prevent this type of incident from occurring again?

  • Action taken to ensure recommendations are considered

  • Date by which all corrective measures will be implemented

  • Signature of supervisor responsible for corrections

Finalization

  • Preparer's signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.