Title Page
Title of Inspection
-
Incident Type
- Near Miss
- First Aid
- Recordable
- Unsafe Condition
- Unsafe Act
- Property Damage
-
Affected Employee:
-
Affected Employee:
-
Affected Employee:
-
Condition and Location:
-
Employee Name:
-
Employee Name:
Incident Report
-
Please select the type of incident:
- Unsafe Condition
- Near Miss
- First Aid
- Property Damage
- Recordable
- Unsafe Act
- 3rd Party Property Damage
-
Department
- Production
- Single Serve
- Maintenance
- Sanitation
- Warehouse
- Quality
- Other
-
Describe Location
-
Employee Name
-
Date and Time of Incident
-
Date Reported
-
Shift
-
Time Employee Began Work
-
Employees usual job title
-
Job at time of incident
-
Length of time on the job before the incident had occurred
-
Describe in detail how the incident occured:
-
Add pictures from incident here:
-
Describe the work in progress (task) when the incident occurred
-
Did anyone witness the incident?
-
Who?
-
Were statements recorded at the Nurse's station?
-
Potential result of an incident
- Other
- Fall from elevation
- Fall, same level
- Slip
- Trip
- Struck against object
- Struck by object
- Caught in, under, between
- Overextension/Strain
- Motor vehicle/Forklift
-
Potentially contacted with/contacted by
- Chemicals
- Electricity
- Temperature Extremes
- Equipment
- Noise
- Radiation
- Insect Bite
- Glass
- Other
- Not Applicable
-
Reference: Complete List of all Causal Factors
-
Causal Factor(s)
- Employee
- Supervision
- Equipment/Materials
- Other
-
Employee
- Physical Limitations
- Deficient in skill/ability
- Drugs/alcohol
- Lack of alertness
- Failure to follow written procedure
- Confined space entry
- LOTO
- Failure to follow oral instructions
- Failure to use PPE
- Operating without authority
- Taking an at risk position
- At risk speed (shortcut)
- Improper use of tool/equipment/material
- Use of incorrect tool/equipment/material
- Improper manual handling
-
Supervision
- Incorrect/incomplete procedures/instructions
- Rules/procedures not enforced
- Inadequate training of employee(s)
- Proper tools/equipment not provided
- Deficient storage/handling practices
- Inadequate housekeeping
- Rush by supervisor
-
Equipment/Materials
- Defective equipment/tools/materials
- Inadequate or missing guards
- Inadequate or bypassed safety devices
- Inadequate maintenance/equipment/inspection
- Inadequate lighting
- Inadequate ventilation
- Inadequate design/layout (congestion)
- Inadequate fabrication/installation
-
Other
- Horseplay/distraction by fellow employee
- Error by fellow employee
- Equipment/material/action of 3rd party
- Upset conditions
- Exposure to chemical/physical/biological agents
- Weather (rain/snow/ice/wind)
- Company sponsored activity
- Glass
- Other
-
Basic Cause(s)
- Lack of knowledge
- Not enforcing proper policies
- Engineering
- Inadequate PPE
- Purchasing inadequate/inferior equipment
- Lack of accountability
- Improper methods
- Inadequate inspection/maintenance
-
Immediate fix
5 Why (Root Cause)
-
1. Why did the incident happen?
-
2. Why did 1 happen?
-
3. Why did 2 happen
-
4. Why did 3 happen?
-
5. Why did 4 happen?
-
-
Department
- Production
- Single Serve
- Maintenance
- Sanitation
- Warehouse
- Quality
- Other
-
Describe Location
-
Employee Name
-
Date and Time of Incident
-
Date Reported
-
Shift
-
Time Employee Began Work
-
Employees usual job title
-
Job at time of incident
-
Length of time on the job before the incident had occurred
-
Describe in detail how the incident occured:
-
Add pictures from incident here:
-
Describe the work in progress (task) when the incident occurred
-
Did anyone witness the incident?
-
Who?
-
Were statements recorded at the Nurse's station?
-
Incident Type
- Caught in, under, between
- Contact by
- Contact with
- Fall from elevation
- Fall, same level
- Motor vehicle / PIT
- Struck against object
- Struck by object
- Other
- Slip
- Trip
- Overexertion / strain
-
Contacted With/Contacted By
- Chemicals
- Electricity
- Temperature Extremes
- Equipment
- Noise
- Radiation
- Insect Bite
- Glass
- Other
- Not Applicable
-
Right or Left Side of Body?
- Right
- Left
-
Right - Body Part Affected
- Head
- Eye(s)
- Ear(s)
- Face
- Neck
- Trunk/Torso
- Shoulders
- Chest
- Back/Spine
- Abdomen/groin
- Hip
- Upper Extremities
- Upper Arm
- Elbow
- Forearm
- Wrist
- Hand
- Finger(s)
- Lower Extremities
- Thigh
- Knee
- Skin/Calf
- Ankle
- Foot
- Toe(s)
- Body systems
- Circulatory
- Respiratory
- Other
-
Left - Body Part Affected
- Head
- Eye(s)
- Ear(s)
- Face
- Neck
- Trunk/Torso
- Shoulders
- Chest
- Back/Spine
- Abdomen/groin
- Hip
- Upper Extremities
- Upper Arm
- Elbow
- Forearm
- Wrist
- Hand
- Finger(s)
- Lower Extremities
- Thigh
- Knee
- Skin/Calf
- Ankle
- Foot
- Toe(s)
- Body systems
- Circulatory
- Respiratory
- Other
-
Nature of Injury
- Amputation
- Fracture/dislocate/crush
- Cut/scrape/puncture/sting
- Bruise/contusion
- Foreign object
- Irritation
- Hernia/rupture
- Avulsion
- Sprain/Strain
- Burn-chemical
- Burn-thermal/electrical
- Heat Stress/sunstroke
- Suffocate/asphyxiate (lack of oxygen)
- Concussion/unconsciousness
- Poisoning - Acute
-
Nature of Illness
- Skin disease or disorder
- Dust disease of the lung(s)
- Respiratory (toxic agents)
- Poisoning (chronic)
- Physical Agents (radiation, etc.)
- Repeated Trauma (noise, CTDs, etc.)
- Other Illness
- Not Applicable
-
Reference: Complete List of all Causal Factors
-
Causal Factor(s)
- Employee
- Supervision
- Equipment/Materials
- Other
-
Employee
- Physical Limitations
- Deficient in skill/ability
- Drugs/alcohol
- Lack of alertness
- Failure to follow written procedure
- Confined space entry
- LOTO
- Failure to follow oral instructions
- Failure to use PPE
- Operating without authority
- Taking an at risk position
- At risk speed (shortcut)
- Improper use of tool/equipment/material
- Use of incorrect tool/equipment/material
- Improper manual handling
-
Supervision
- Incorrect/incomplete procedures/instructions
- Rules/procedures not enforced
- Inadequate training of employee(s)
- Proper tools/equipment not provided
- Deficient storage/handling practices
- Inadequate housekeeping
- Rush by supervisor
-
Equipment/Materials
- Defective equipment/tools/materials
- Inadequate or missing guards
- Inadequate or bypassed safety devices
- Inadequate maintenance/equipment/inspection
- Inadequate lighting
- Inadequate ventilation
- Inadequate design/layout (congestion)
- Inadequate fabrication/installation
-
Other
- Horseplay/distraction by fellow employee
- Error by fellow employee
- Equipment/material/action of 3rd party
- Upset conditions
- Exposure to chemical/physical/biological agents
- Weather (rain/snow/ice/wind)
- Company sponsored activity
- Glass
- Other
-
Basic Cause(s)
- Lack of knowledge
- Not enforcing proper policies
- Engineering
- Inadequate PPE
- Purchasing inadequate/inferior equipment
- Lack of accountability
- Improper methods
- Inadequate inspection/maintenance
-
Immediate fix
5 Why (Root Cause)
-
1. Why did the incident happen?
-
2. Why did 1 happen?
-
3. Why did 2 happen
-
4. Why did 3 happen?
-
5. Why did 4 happen?
-
Department
- Production
- Single Serve
- Maintenance
- Sanitation
- Warehouse
- Quality
- Other
-
Describe Location
-
Employee Name
-
Date and Time of Incident
-
Date Reported
-
Shift
-
Time Employee Began Work
-
Employees usual job title
-
Job at time of incident
-
Length of time on the job before the incident had occurred
-
OSHA Class
- Other Recordable Injury
- Job Transfer or Restriction of Work
- Days Away From Work
- Fatality
- Occupational Illness
-
Describe in detail how the incident occurred:
-
Add pictures from incident here:
-
Describe the work in progress (task) when the incident occurred
-
Did anyone witness the incident?
-
Who?
-
Were statements recorded at the Nurse's station?
-
Incident Type
- Caught in, under, between
- Contact by
- Contact with
- Fall from elevation
- Fall, same level
- Motor vehicle / PIT
- Struck against object
- Struck by object
- Other
- Slip
- Trip
- Overexertion / strain
-
Contacted With/Contacted By
- Chemicals
- Electricity
- Temperature Extremes
- Equipment
- Noise
- Radiation
- Insect Bite
- Glass
- Other
- Not Applicable
-
Description of Injury/Illness
- Medical Only
- Lost Time-Restricted Work
- Lost Time-Away From Work
- Fatality
-
Right or Left Side of Body?
- Right
- Left
-
Right - Body Part Affected
- Head
- Eye(s)
- Ear(s)
- Face
- Neck
- Trunk/Torso
- Shoulders
- Chest
- Back/Spine
- Abdomen/groin
- Hip
- Upper Extremities
- Upper Arm
- Elbow
- Forearm
- Wrist
- Hand
- Finger(s)
- Lower Extremities
- Thigh
- Knee
- Skin/Calf
- Ankle
- Foot
- Toe(s)
- Body systems
- Circulatory
- Respiratory
- Other
-
Left - Body Part Affected
- Head
- Eye(s)
- Ear(s)
- Face
- Neck
- Trunk/Torso
- Shoulders
- Chest
- Back/Spine
- Abdomen/groin
- Hip
- Upper Extremities
- Upper Arm
- Elbow
- Forearm
- Wrist
- Hand
- Finger(s)
- Lower Extremities
- Thigh
- Knee
- Skin/Calf
- Ankle
- Foot
- Toe(s)
- Body systems
- Circulatory
- Respiratory
- Other
-
Nature of Injury
- Amputation
- Fracture/dislocate/crush
- Cut/scrape/puncture/sting
- Bruise/contusion
- Foreign object
- Irritation
- Hernia/rupture
- Avulsion
- Sprain/Strain
- Burn-chemical
- Burn-thermal/electrical
- Heat Stress/sunstroke
- Suffocate/asphyxiate (lack of oxygen)
- Concussion/unconsciousness
- Poisoning - Acute
-
Nature of Illness
- Skin disease or disorder
- Dust disease of the lung(s)
- Respiratory (toxic agents)
- Poisoning (chronic)
- Physical Agents (radiation, etc.)
- Repeated Trauma (noise, CTDs, etc.)
- Other Illness
- Not Applicable
-
Reference: Complete List of all Causal Factors
-
Causal Factor(s)
- Employee
- Supervision
- Equipment/Materials
- Other
-
Employee
- Physical Limitations
- Deficient in skill/ability
- Drugs/alcohol
- Lack of alertness
- Failure to follow written procedure
- Confined space entry
- LOTO
- Failure to follow oral instructions
- Failure to use PPE
- Operating without authority
- Taking an at risk position
- At risk speed (shortcut)
- Improper use of tool/equipment/material
- Use of incorrect tool/equipment/material
- Improper manual handling
-
Supervision
- Incorrect/incomplete procedures/instructions
- Rules/procedures not enforced
- Inadequate training of employee(s)
- Proper tools/equipment not provided
- Deficient storage/handling practices
- Inadequate housekeeping
- Rush by supervisor
-
Equipment/Materials
- Defective equipment/tools/materials
- Inadequate or missing guards
- Inadequate or bypassed safety devices
- Inadequate maintenance/equipment/inspection
- Inadequate lighting
- Inadequate ventilation
- Inadequate design/layout (congestion)
- Inadequate fabrication/installation
-
Other
- Horseplay/distraction by fellow employee
- Error by fellow employee
- Equipment/material/action of 3rd party
- Upset conditions
- Exposure to chemical/physical/biological agents
- Weather (rain/snow/ice/wind)
- Company sponsored activity
- Glass
- Other
-
Basic Cause(s)
- Lack of knowledge
- Not enforcing proper policies
- Engineering
- Inadequate PPE
- Purchasing inadequate/inferior equipment
- Lack of accountability
- Improper methods
- Inadequate inspection/maintenance
-
Immediate fix
5 Why (Root Cause)
-
1. Why did the incident happen?
-
2. Why did 1 happen?
-
3. Why did 2 happen
-
4. Why did 3 happen?
-
5. Why did 4 happen?
-
Damage to company property will result in disciplinary action based on the following.
-
Department
- Production
- Single Serve
- Maintenance
- Sanitation
- Warehouse
- Quality
- Other
-
Describe Location
-
Employee(s) Name
-
Date and Time of Incident
-
Date Reported
-
Shift
-
Time Employee(s) Began Work
-
Employees usual job title
-
Job at time of incident
-
Length of time on the job before the incident had occurred
-
Describe in detail how the incident occured:
-
Add pictures from incident here:
-
Describe the work in progress (task) when the incident occurred
-
Did anyone witness the incident?
-
Who?
-
Were statements recorded at the Nurse's station?
-
Incident Type
- Caught in, under, between
- Contact by
- Contact with
- Fall from elevation
- Fall, same level
- Motor vehicle / PIT
- Struck against object
- Struck by object
- Other
- Slip
- Trip
- Overexertion / strain
-
Contacted With/Contacted By
- Chemicals
- Electricity
- Temperature Extremes
- Equipment
- Noise
- Radiation
- Insect Bite
- Glass
- Other
- Not Applicable
-
Reference: Complete List of all Causal Factors
-
Causal Factor(s)
- Employee
- Supervision
- Equipment/Materials
- Other
-
Employee
- Physical Limitations
- Deficient in skill/ability
- Drugs/alcohol
- Lack of alertness
- Failure to follow written procedure
- Confined space entry
- LOTO
- Failure to follow oral instructions
- Failure to use PPE
- Operating without authority
- Taking an at risk position
- At risk speed (shortcut)
- Improper use of tool/equipment/material
- Use of incorrect tool/equipment/material
- Improper manual handling
-
Supervision
- Incorrect/incomplete procedures/instructions
- Rules/procedures not enforced
- Inadequate training of employee(s)
- Proper tools/equipment not provided
- Deficient storage/handling practices
- Inadequate housekeeping
- Rush by supervisor
-
Equipment/Materials
- Defective equipment/tools/materials
- Inadequate or missing guards
- Inadequate or bypassed safety devices
- Inadequate maintenance/equipment/inspection
- Inadequate lighting
- Inadequate ventilation
- Inadequate design/layout (congestion)
- Inadequate fabrication/installation
-
Other
- Horseplay/distraction by fellow employee
- Error by fellow employee
- Equipment/material/action of 3rd party
- Upset conditions
- Exposure to chemical/physical/biological agents
- Weather (rain/snow/ice/wind)
- Company sponsored activity
- Glass
- Other
-
Basic Cause(s)
- Lack of knowledge
- Not enforcing proper policies
- Engineering
- Inadequate PPE
- Purchasing inadequate/inferior equipment
- Lack of accountability
- Improper methods
- Inadequate inspection/maintenance
-
EMPLOYEE PLACEMENT - Improper matching of the affected employee's skill set to what the job or specific task demands that led to an injury or incident.
-
Immediate fix
5 Why (Root Cause)
-
1. Why did the incident happen?
-
2. Why did 1 happen?
-
3. Why did 2 happen
-
4. Why did 3 happen?
-
5. Why did 4 happen?
-
Date and time of incident
-
Describe the unsafe act
-
Add pictures of the unsafe act here:
-
Describe what was done to immediately improve, correct or respond to observation
-
Did your actions correct the observation?
-
If No, how should the observation be corrected?
-
Date and time of incident
-
Describe the unsafe condition
-
Add pictures of the unsafe condition here:
-
Describe what was done to immediately improve, correct or respond to observation
-
Did your actions correct the observation?
-
If No, how should the observation be corrected?
-
Date and time of incident
-
What was damaged (be specific)
-
Party responsible for damage
-
Name of individual(s) responsible
-
Describe in detail how the incident occurred:
-
Describe the work in progress (task) when the incident occurred
-
Information obtained during or after the incident?
-
Provide here:
-
Was plant security or a member of management notified by the 3rd party of the damage
-
File a report with local law enforcement if property was damaged and the responsible party left without notifying plant management/security. Local Police: 419-332-6464
-
Pictures of damage
-
Did anyone witness the incident?
-
Who?
-
Estimated cost of damage (needed for claim)
-
CONSULT WITH OTHER CONTRACTOR THAT MAY BE ABLE TO ASSIST WITH DETERMING COST OF DAMAGES
5 Why (Root Cause)
-
1. Why did the incident happen?
-
2. Why did 1 happen?
-
3. Why did 2 happen
-
4. Why did 3 happen?
-
5. Why did 4 happen?
Sending the Report
-
With a mobile device: Send the report.
Complete Inspection → View & Export Report → Email -
Supervisor Signature