Facility 5 Injury Investigation Report - Greenheck

• Site conducted

  Select

• Investigation Date

  Date

• Investigator(s)

Instructions

• INSTRUCTIONS
  1. Please answer all questions below.
  2. Add Photos in "Media" and Comments in "Add note..." on each question as needed.
  3. When complete, please email Nic Schmitt and the Safety Team Leads on each shift, notifying them that the report is ready in iAuditor.

Initial Information

• Injured Team Member Name

• Injured Team Member Clock Number

• Date Incident Occurred

  Date

• Supervisor Who Filled out the Corporate Injury Investigation Report

Sequence of Events (Incident Should be the Last Event): Facts of what occurred up to incident

• 01 What Happened?

• Cause/Why?

• 02 What Happened?

• Cause/Why?

• 03 What Happened?

• Cause/Why?

• 04 What Happened?

• Cause/Why?

• 05 What Happened?

• Cause/Why?

• 06 What Happened?

• Cause/Why?

Additional Information

• Tool/Machine Involved?

  Yes

  No

  N/A

• What Machine?

• Material/Product Involved?

  Yes

  No

  N/A

• What (gauge/thickness, size, weight, model, color, SO#, PO#)

• Workstation Height Relative to Team Member?

  Too High

  Too Low

  Correct

• Unsafe Behavior (Example: Improper Hand Placement, Awareness)?

• Environment (Outside Conditions, Lighting, Substance on Floor, etc.)?

Root Cause

• What is the root cause?

Corrective Action (this will be discussed with the safety team)

• What is a possible corrective action?