General Incident Report (GIR)

• Instructions: This form must be used to investigate all work-related incidents resulting in injury regardless of severity. It is requested Supervisors or other designee complete this form and submit it to the Safety Director within 24 hours of the event.

• WHEN DETERMINING INCIDENT CONTRIBUTING FACTORS, REMEMBER THE FOLLOWING:
  
  1. The team member’s actions made sense to them at the time of the incident (circumstances and perceptions).
  2. Look beyond the individual(s) involved in the incident (focus on the incident, not the individual).
  3. The Root Cause Analysis RCA process must be focused on fact, not fault finding.
  4. Determine error precursors and flawed or missing safeguards that contributed to the incident

1. General Information

• Employee(s) Involved:

• Job Title:

• Incident Date & Time:

  Date

• Empire Office Unit Location:

  Select

• Address where event occurred

• What Object(s) Directly Harmed the Employee?

• Were There Any Witnesses?

  Yes

  No

• Were Statements Obtained?

  Yes

  No

  Pending

• Was This an Injury, Illness, or Other?

  Injury

  Illness

  Other

• Please Explain Other:

• Was a Doctor Seen?

  Yes

  No

• Doctor's Name

• Treating Facility Name

• Phone Number

• Treating Facility Address

• If the event resulted in Injury, what was the nature of the injury?

  Select Heat/Cold Burn Chemical Inhalation Sprain Struck-by Electrical Shock Foreign Body Strain Slip Physical Exhaustion Heat/ColdStress Contusion/Bruise Trip Cut/Laceration Chemical Burn Chemical Irritation Fall Other

  • Heat/Cold Burn
  • Chemical Inhalation
  • Sprain
  • Struck-by
  • Electrical Shock
  • Foreign Body
  • Strain
  • Slip
  • Physical Exhaustion
  • Heat/ColdStress
  • Contusion/Bruise
  • Trip
  • Cut/Laceration
  • Chemical Burn
  • Chemical Irritation
  • Fall
  • Other

• Please Explain Other:

• Classification?

  Select Dr.Visit/Evaluation Only First Aid Medical Treatment Restrictive Duty Loss Time Other

  • Dr.Visit/Evaluation Only
  • First Aid
  • Medical Treatment
  • Restrictive Duty
  • Loss Time
  • Other

• Please Explain Other:

• NOTE: Be prepared to provide the employee’s SSN and pay rate for loss time injuries when reporting loss time injuries to ESIS.

• Please select all that apply

Work Rules/Practices

• Factor(s)

  Select Not followed Not understood Not established Action of Co-Worker Improper Procedure Inattention Lack of training Horseplay Disregard for safety Other N/A - Not Applicable

  • Not followed
  • Not understood
  • Not established
  • Action of Co-Worker
  • Improper Procedure
  • Inattention
  • Lack of training
  • Horseplay
  • Disregard for safety
  • Other
  • N/A - Not Applicable

• Please indicate

Tools/Equipment

• Factor(s)

  Select Controllable Physical Defect Uncontrollable Physical Defect Guarding Deficiency/Defect Working on Moving Equipment Defective Tools or Equipment Improper Tools or Equipment Bypass Safety Device Improper Lockout/Tagout Other N/A - Not Applicable

  • Controllable Physical Defect
  • Uncontrollable Physical Defect
  • Guarding Deficiency/Defect
  • Working on Moving Equipment
  • Defective Tools or Equipment
  • Improper Tools or Equipment
  • Bypass Safety Device
  • Improper Lockout/Tagout
  • Other
  • N/A - Not Applicable

• Please indicate

Motivation

• Factor(s)

  Select Workload Schedule Temperature Extremes/Weather Distraction Excessive Overtime/Fatigue Lack of Supervision Working Beyond Skill Level Speed of Work Other N/A - Not Applicable

  • Workload
  • Schedule
  • Temperature Extremes/Weather
  • Distraction
  • Excessive Overtime/Fatigue
  • Lack of Supervision
  • Working Beyond Skill Level
  • Speed of Work
  • Other
  • N/A - Not Applicable

• Please indicate

Maintenance

• Factor(s)

  Select No PM Schedule Incomplete PM Schedule Maintenance Deficiencies Other N/A - Not Applicable

  • No PM Schedule
  • Incomplete PM Schedule
  • Maintenance Deficiencies
  • Other
  • N/A - Not Applicable

• Please indicate

Engineering

• Factor(s)

  Select Engineering Deficiencies No Standardized Procedure Inadequate Standards/Procedures Other N/A - Not Applicable

  • Engineering Deficiencies
  • No Standardized Procedure
  • Inadequate Standards/Procedures
  • Other
  • N/A - Not Applicable

• Please indicate

Other

• Factor(s)

  Select Not Using PPE Improper Selection of PPE Improper Body Mechanics Housekeeping Other N/A - Not Applicable

  • Not Using PPE
  • Improper Selection of PPE
  • Improper Body Mechanics
  • Housekeeping
  • Other
  • N/A - Not Applicable

• Please indicate

• Provide a detailed description of the incident root cause(s).

• Corrective actions to be taken to prevent recurrence:

• Report was completed by:

• Your title:

• Your signature:

  Sign

• Today's date:

  Date