Incident Analysis

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Team Member- Basic Information

• (A) Perspective Report #

• (B) Team Member Name ( Last, First, MI)

• (C) Incident Date and Time

  Date

• (D) Date Incident Reported

  Date

• Employment Status

  Full Time

  Part Time

• Regular Job

• Job Performing

• Department

• Date of Hire

  Date

• Date in Current Job

  Date

• Experience with Job Task

  Frequent

  Infrequent

  None

• Length of Shift (in hrs)

• Shift

  Days

  Swings

  Graves

• Shift Start Time

  Date

• Type of Shift

  Fixed

  Flexed

• Team Member Days Off

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

Incident Information

• Incident Type

  Injury

  Illness

  Fatality

  Near-miss

  Damage Only

• Exact Location of Incident ( if off property, give address)

• Equipment or Materials Involved

• Contact Agent (the exact object/material that caused injury)

• Describe The Incident

• Provide a Drawing if Helpful

  Drawing

• Please Add a Photo When Applicable

  Media

Incident Type

• Type of Incident

  Select Unknown Struck Against Struck By Fall-Elevation Fall-Same Level Caught In/Under/Between Bodily Reaction Overexertion Contact With Exposure Inhalation Ingestion Other

  • Unknown
  • Struck Against
  • Struck By
  • Fall-Elevation
  • Fall-Same Level
  • Caught In/Under/Between
  • Bodily Reaction
  • Overexertion
  • Contact With
  • Exposure
  • Inhalation
  • Ingestion
  • Other

• Please Describe

Incident Analysis

• Environment

  Select Physical Hazard Hazardous Chemical Lighting Noise Weather Terrain Vibration Ergonomics Leaks/Spills Temperature Housekeeping Biological Agent Other

  • Physical Hazard
  • Hazardous Chemical
  • Lighting
  • Noise
  • Weather
  • Terrain
  • Vibration
  • Ergonomics
  • Leaks/Spills
  • Temperature
  • Housekeeping
  • Biological Agent
  • Other

• Please Describe

• Team Member

  Lack of Knowledge

  Knew Process/Procedure

• Mark All That Apply

  Never Trained

  Trained-Forgot or Inadequate Training

• Mark All That Apply

  Hurrying/Rushing

  Anger/Frustration

  Tired/Fatigued

  Complacent/Distracted/day Dreaming

• Mark All Applicable

  Body in Line of Energy

  Loss of Balance

  Loss of Traction

  Loss of Grip

  Improper Body Position or Stress from Repeated Activity

• Equipment

  Select Selection Availability Maintenance Guarding Replacement Visual Warning Other

  • Selection
  • Availability
  • Maintenance
  • Guarding
  • Replacement
  • Visual Warning
  • Other

• Please Describe

• Management (Must have at least one checked)

  Select Policy Enforcement Hazard Recognition Accountabiliy Knowledge/Training Coaching Task Process Maintenance/Repair Staffing/Shifts Physical Layout Equipment/Supplies Other

  • Policy Enforcement
  • Hazard Recognition
  • Accountabiliy
  • Knowledge/Training
  • Coaching
  • Task Process
  • Maintenance/Repair
  • Staffing/Shifts
  • Physical Layout
  • Equipment/Supplies
  • Other

• Please Describe

Preventive Measures

• What Action Has Been Taken or is Planned to Prevent Recurrence

  Select Re-Instruction/Retraining Training Coaching Training for Leaders Development of Training Improve Job Task/Procedure Improve Housekeeping Job Hazard Analysis Needed Guard/Safety Device PPE Tools/Equipment Replaced or Repaired Eliminate Congestion Improve Design/Construction Substitute Safer Materials/Supplies/Chemicals Improve Illumination Improve Ventilation Reduction in Noise/Vibration Enforce Procedures Other

  • Re-Instruction/Retraining
  • Training
  • Coaching
  • Training for Leaders
  • Development of Training
  • Improve Job Task/Procedure
  • Improve Housekeeping
  • Job Hazard Analysis Needed
  • Guard/Safety Device
  • PPE
  • Tools/Equipment Replaced or Repaired
  • Eliminate Congestion
  • Improve Design/Construction
  • Substitute Safer Materials/Supplies/Chemicals
  • Improve Illumination
  • Improve Ventilation
  • Reduction in Noise/Vibration
  • Enforce Procedures
  • Other

• Please Describe

• How Will The Above Action(s) Improve Operations?

Signature and Review

• NOTE: I have reviewed this report, I am confident that the incident was thoroughly analyzed and proper actions have been taken or are planned to be taken to prevent recurrence.

• Analysis By (Immediate Supervisor)

  Sign

• Team Member Involved

  Sign