Highbury Concrete Inc Incident Investigation Report - duplicate - local copy - local copy

• This is a report of a:

  Death

  Lost Time

  Dr. Visit Only

  First Aid Only

  Near Miss

• Date of Incident

  Date

• This report is made by:

  Employee

  Supervisor

  Team

  Other

• Prepared by

• Location
  Address

• Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness.
  (Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)

Step 1: Injured employee (complete this part for each injured employee)

• Employee headshot

  Media

• Does employee understand that any incident which involves an employee getting hurt must be reported immediately?

  Yes

  No

• Did employee immediately report the injury? (If so create a note indicating whom injury was reported to.)

  Yes

  No

• Was accident report form filled out and sent to Human Resources? (If so attach accident report form below.)

  Yes

  No

• Employee Name

• Employee ID #

• Sex

  Male

  Female

• Address

• Phone number

• Date of birth

  Date

• Job title

• Part(s) of body affected: (indicate all that apply.)

  Drawing

• Nature of injury:

  Select Minor abrasion, scrapes Broken bone Bruise Burn (heat) Burn (chemical) Concussion (to the head) Crushing Injury Cut, laceration, puncture Hernia Illness Sprain, strain Damage to a body system Slip, trip or fall Other Eye injury

  • Minor abrasion, scrapes
  • Broken bone
  • Bruise
  • Burn (heat)
  • Burn (chemical)
  • Concussion (to the head)
  • Crushing Injury
  • Cut, laceration, puncture
  • Hernia
  • Illness
  • Sprain, strain
  • Damage to a body system
  • Slip, trip or fall
  • Other
  • Eye injury

• This employee works:

  Regular full time

  Regular part time

  Seasonal

  Temporary

• Length of employment

• Field experience

• Supervisor Name

• Supervisor phone number

• Firs aid procedure (if any)

• If employee saw a Doctor (Doctors name, phone number, and medical facility)

• If employee saw a Doctor was employee medically cleared to work on RTW form (return to work form)

  Yes, resumed normal work activity.

  Yes, on light duty.

  Yes, on modified duty.

  No.

• Notes:

• RTW form (return to work form)

  Media

Step 2: Describe the incident

• Exact location of the incident

• Time of incident

  Date

• What part of employee’s workday?

  Select Entering or leaving work Doing normal work activities During meal period During break Working overtime Other

  • Entering or leaving work
  • Doing normal work activities
  • During meal period
  • During break
  • Working overtime
  • Other

• Names of witnesses (if any)

• Written witness statements:

  Media

• Photo(s) of injury:

  Media

• Photos of the scene:

  Media

• Employees credentials

  Media

• What personal protective equipment was being used (if any)?

• Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details.

Step 3: What caused or potentially caused the incident to happen?

• Select all that apply

  Select Inadequate guard Unguarded hazard Safety device is defective Tool or equipment defective Workstation layout is hazardous Unsafe lighting Unsafe ventilation Lack of needed personal protective equipment Lack of appropriate equipment / tools Unsafe clothing Insufficient training Insubordination Other

  • Inadequate guard
  • Unguarded hazard
  • Safety device is defective
  • Tool or equipment defective
  • Workstation layout is hazardous
  • Unsafe lighting
  • Unsafe ventilation
  • Lack of needed personal protective equipment
  • Lack of appropriate equipment / tools
  • Unsafe clothing
  • Insufficient training
  • Insubordination
  • Other

• Unsafe acts by people: (Select all that apply)

  Select Operating without permission Operating at unsafe speed Servicing equipment that has power to it Making a safety device inoperative Using defective equipment Using equipment in an unapproved way Unsafe lifting Taking an unsafe position or posture Distraction, teasing, horseplay Failure to wear personal protective equipment Failure to use the available equipment / tools Other

  • Operating without permission
  • Operating at unsafe speed
  • Servicing equipment that has power to it
  • Making a safety device inoperative
  • Using defective equipment
  • Using equipment in an unapproved way
  • Unsafe lifting
  • Taking an unsafe position or posture
  • Distraction, teasing, horseplay
  • Failure to wear personal protective equipment
  • Failure to use the available equipment / tools
  • Other

• Were any unsafe acts or conditions reported prior to the incident?

  Yes

  No

• Have there been similar incidents or near misses prior to this one?

  Yes

  No

Step 4: How can future incidents be prevented?

• What should be (or has been) done to carry out the suggestion(s) checked above?

Step 5: Who completed and reviewed this form?

• I have provided the information on this report and reviewed it to ensure that it was accurately recorded.

  Sign

• Written by

  Sign

• Title