EPUD - Incident Report

• Audit Title

• Conducted on

  Date

• Prepared by

• Location
  Address

• Incident Fact Finding Form

• Date and Time of Incident

  Date

• Employee Classification

  Full Time

  Part Time

  Temporary

  Contractor

• Foreman/Supervisor

Damage

• Utility Property

• 3rd Party

• Saw Doctor

Personal Injury

• Near Miss

• Accident

• Loss Incurred

Injury/Illness

• First Aid

• Medical Treatment

• Saw Doctor

Vehicle Incident

• Preventable

• Non-Preventable

• Police Present

• Brief Description of Events & Extent of Injury/Damage

• Was there a written or verbal safety rule or procedure for the activity involved?

  Yes

  No

  N/A

• What was the number or paragraph?

• Section I: Detailed Sequence of Events

• 1. Time

  Date

• Event Description

• 2. Time

  Date

• Event Description

• 3. Time

  Date

• Event Description

• 4. Time

  Date

• Event Description

• 5. Time

  Date

• Event Description

• 6. Time

  Date

• Event Description

• 7. Time

  Date

• Event Description

• 8. Time

  Date

• Event Description

• 9. Time

  Date

• Event Description

• 10. Time

  Date

• Event Description

• 11. Time

  Date

• Event Description

• 12. Time

  Date

• Event Description

• Section II: Personal Injury Or Near Miss

• Type of Event

  Select Struck Against (Running/Bumping) Struck By (Hit By Moving Object) Fall From Elevation to Lower Level Fall on Same Level (Slip/Trip/Fall) Caught In (Pinch/Nip) Caught On (Snagged/Hung) Caught Between/Under (Crush/Amputated) Poison Oak Foreign Body Cut/Laceration Fracture Contact With (Electricity/Heat/Cold/Radiation) Contact With (Caustic/Toxic/Bio/Noise) Abnormal Operation Product Contamination Over-Stress/Pressure/Exert/Ergo Equipment Failure Environmental Release/Exposure (Heat/Cold) Animal Bite Sprain/Strain Abrasion/Bruise Other

  • Struck Against (Running/Bumping)
  • Struck By (Hit By Moving Object)
  • Fall From Elevation to Lower Level
  • Fall on Same Level (Slip/Trip/Fall)
  • Caught In (Pinch/Nip)
  • Caught On (Snagged/Hung)
  • Caught Between/Under (Crush/Amputated)
  • Poison Oak
  • Foreign Body
  • Cut/Laceration
  • Fracture
  • Contact With (Electricity/Heat/Cold/Radiation)
  • Contact With (Caustic/Toxic/Bio/Noise)
  • Abnormal Operation
  • Product Contamination
  • Over-Stress/Pressure/Exert/Ergo
  • Equipment Failure
  • Environmental Release/Exposure (Heat/Cold)
  • Animal Bite
  • Sprain/Strain
  • Abrasion/Bruise
  • Other

• Part of Body Affected

  Select Scalp Shoulder Skull Upper Arm Neck Elbow Ears Forearm Eyes Wrist Mouth Hand Teeth Fingers Face Upper Back Thigh Lower Back Lower Leg Chest Knee Abdomen Foot Hip Toe (s) Groin Ankle Side Other

  • Scalp
  • Shoulder
  • Skull
  • Upper Arm
  • Neck
  • Elbow
  • Ears
  • Forearm
  • Eyes
  • Wrist
  • Mouth
  • Hand
  • Teeth
  • Fingers
  • Face
  • Upper Back
  • Thigh
  • Lower Back
  • Lower Leg
  • Chest
  • Knee
  • Abdomen
  • Foot
  • Hip
  • Toe (s)
  • Groin
  • Ankle
  • Side
  • Other

• Personal Protective Equipment

  Select Hard Hat Work Boots Safety Glasses Gloves Hearing Protection Harness High Visibility Seat Belt Rubber Gloves Personal Grounds Cover FR Clothing Not Available Not Required Other

  • Hard Hat
  • Work Boots
  • Safety Glasses
  • Gloves
  • Hearing Protection
  • Harness
  • High Visibility
  • Seat Belt
  • Rubber Gloves
  • Personal Grounds
  • Cover
  • FR Clothing
  • Not Available
  • Not Required
  • Other

• Immediate/Direct Causes - Substandard Act (s)

  Select Operating Equipment w/out Authority/Training Failure to Warn Failure to Secure Operating at Improper Speed Making Safety Devices Inoperative Using Defective Equipment Failing to Use PPE Properly Improper Loading of Equipment/Materials Improper Placement Improper Lifting Improper Position for the Task Servicing Equipment in Operation Horseplay Under Influence of Alcohol/Other Drugs Using Equipment Improperly Failure to Follow Procedure/Policy/Practice Failure to Identify Hazard/Risk Failure to Check/Monitor Failure to React/Correct Failure to Communicate/Coordinate Other

  • Operating Equipment w/out Authority/Training
  • Failure to Warn
  • Failure to Secure
  • Operating at Improper Speed
  • Making Safety Devices Inoperative
  • Using Defective Equipment
  • Failing to Use PPE Properly
  • Improper Loading of Equipment/Materials
  • Improper Placement
  • Improper Lifting
  • Improper Position for the Task
  • Servicing Equipment in Operation
  • Horseplay
  • Under Influence of Alcohol/Other Drugs
  • Using Equipment Improperly
  • Failure to Follow Procedure/Policy/Practice
  • Failure to Identify Hazard/Risk
  • Failure to Check/Monitor
  • Failure to React/Correct
  • Failure to Communicate/Coordinate
  • Other

• Immediate/Direct Causes - Substandard Condition (s)

  Select Inadequate Guards/Barriers Inadequate/Improper Protective Equipment Defective Tools, Equipment or Materials Congestion/Restricted Action Inadequate Warning System Fire & Explosion Hazards Poor Housekeeping/Disorder Noise Exposure Radiation Exposure Temperature Extremes Inadequate/Excess Illumination Inadequate Ventilation Presence of Harmful Materials Inadequate Instructions/Procedures Inadequate Information/Data Inadequate Preparation/Planning Inadequate Support/Assistance Inadequate Communication Road Conditions Other

  • Inadequate Guards/Barriers
  • Inadequate/Improper Protective Equipment
  • Defective Tools, Equipment or Materials
  • Congestion/Restricted Action
  • Inadequate Warning System
  • Fire & Explosion Hazards
  • Poor Housekeeping/Disorder
  • Noise Exposure
  • Radiation Exposure
  • Temperature Extremes
  • Inadequate/Excess Illumination
  • Inadequate Ventilation
  • Presence of Harmful Materials
  • Inadequate Instructions/Procedures
  • Inadequate Information/Data
  • Inadequate Preparation/Planning
  • Inadequate Support/Assistance
  • Inadequate Communication
  • Road Conditions
  • Other

• Basic/Root Causes/System Factors

  Select Inadequate Leadership and/or Supervision Inadequate Purchasing Inadequate Tools/Equipment Excessive Wear and Tear Inadequate Engineering Inadequate Maintenance Inadequate Work Standards Inadequate Communications Other

  • Inadequate Leadership and/or Supervision
  • Inadequate Purchasing
  • Inadequate Tools/Equipment
  • Excessive Wear and Tear
  • Inadequate Engineering
  • Inadequate Maintenance
  • Inadequate Work Standards
  • Inadequate Communications
  • Other

• Section III: Vehicle Incident

• Type of Event

• Did the incident happen on the driven roadway?

  Yes

  No

  N/A

• Did the incident happen off the driven roadway?

  Yes

  No

  N/A

• Was there damage to the utility vehicle?<br>

  Yes

  No

  N/A

• Were there injuries to either party?

  Yes

  No

  N/A

• Was the vehicle 26,000 lbs or bigger?

  Yes

  No

  N/A

• Did the driver have a current CDL and Medical Card?

  Yes

  No

  N/A

• Was substance testing performed?

  Yes

  No

  N/A

• Was an enforcement agency present and conducting an investigation?

  Yes

  No

  N/A

• Was a DOT report filed?

  Yes

  No

  N/A

• Was a DMV report filed?

  Yes

  No

  N/A

• Was an insurance report filed?

  Yes

  No

  N/A

• Any Other Information/Explanation

• Check One

  Select Collision with Vehicle Moving in Same Direction Running Into/Sideswiping Stationary Vehicle Running Into/Sideswiping Object at Roadside Struck by Vehicle While Stationary on Roadway Struck by Vehicle While Stationary Off Roadway Other Non-Collision Accidents Collision w/Vehicle Moving in Opposite Direction Struck Pedestrian Backing Into Object or Vehicle Damage by Object in Roadway Mechanical Failure Struck by Object Falling from Another Vehicle Collision Involving Animal Collision Involving Pedal Cycle Collision w/Vehicle Moving in Perpendicular Direction Other

  • Collision with Vehicle Moving in Same Direction
  • Running Into/Sideswiping Stationary Vehicle
  • Running Into/Sideswiping Object at Roadside
  • Struck by Vehicle While Stationary on Roadway
  • Struck by Vehicle While Stationary Off Roadway
  • Other Non-Collision Accidents
  • Collision w/Vehicle Moving in Opposite Direction
  • Struck Pedestrian
  • Backing Into Object or Vehicle
  • Damage by Object in Roadway
  • Mechanical Failure
  • Struck by Object Falling from Another Vehicle
  • Collision Involving Animal
  • Collision Involving Pedal Cycle
  • Collision w/Vehicle Moving in Perpendicular Direction
  • Other

• Contributing Factors

  Select Following Too Closely Failure to Signal Intentions Speed Too Fast for Conditions Disregarded Traffic Signals/Signs Improper Passing Improper Turning Improper Backing Failure to Leave Sufficient Room Failure to Check Cross Traffic Pulled Out Into Oncoming Traffic Driver Violated DMV Rules/Laws Driver Used Poor Judgement Improper Lane Change Improper Parking Other

  • Following Too Closely
  • Failure to Signal Intentions
  • Speed Too Fast for Conditions
  • Disregarded Traffic Signals/Signs
  • Improper Passing
  • Improper Turning
  • Improper Backing
  • Failure to Leave Sufficient Room
  • Failure to Check Cross Traffic
  • Pulled Out Into Oncoming Traffic
  • Driver Violated DMV Rules/Laws
  • Driver Used Poor Judgement
  • Improper Lane Change
  • Improper Parking
  • Other

• Add media

  Media

• Add drawing

  Drawing

• Section IV : Safety Committee

• Safety Committee Recommendations

• List of Employees/Witnesses Interviewed (Name/Title/Contact Information)

• Conclusions - Investigator Findings

• Recommendation Completed By

  Sign

• Recommendation Completed By

  Sign

• Reviewed By Safety Committee Chairman

  Sign

• Reviewed by Supervisor/Foreman

  Sign

• Reviewed by Manager

  Sign