Incident Investigation - Key Cooperative

• Incident Title

• Department / Key Cooperative Location

• Incident Site
  Address

• Conducted on

  Date

• Prepared by

• Yes

  No

  N/A

CONTACTS

• INVESTIGATION CONTACTS (Include address and phone numbers for ALL involved parties)

INTRODUCTION

• DATE & TIME OF INCIDENT

  Date
• LOCATION OF INCIDENT
  Address

BACKGROUND (Provide details leading up to start of incident--include: weather conditions, traffic conditions, other pertinent background information)

• BACKGROUND

SEQUENCE OF EVENTS

• SEQUENCE OF EVENTS

INDICATION OF INJURIES

• WERE THERE ANY INJURIES?

  YES

  NO

• SELECT AREA OF INJURY?

  Select 1) Head 2) Neck 3) Chest 4) Adbomen 5) Shoulder 6) Arms 7) Elbow 8) Forearm 9) Wrist 10) Hand 11) Hip 12) Thigh 13) Knee 14) Calf 15) Top of foot 16) Foot 17) Nape 18) Lumber region 19) Buttock

  • 1) Head
  • 2) Neck
  • 3) Chest
  • 4) Adbomen
  • 5) Shoulder
  • 6) Arms
  • 7) Elbow
  • 8) Forearm
  • 9) Wrist
  • 10) Hand
  • 11) Hip
  • 12) Thigh
  • 13) Knee
  • 14) Calf
  • 15) Top of foot
  • 16) Foot
  • 17) Nape
  • 18) Lumber region
  • 19) Buttock

• DETAILS OF INJURY?

• PHOTOGRAPHS OF INJURY

  Media

INDICATION OF DAMAGE TO PROPERTY

• WAS THERE ANY DAMAGE TO PROPERTY?

  YES

  NO

• RECORD DETAILS AND EXTENT OF DAMAGE (Include vehicle unit and VIN number)

• PHOTOGRAPHS OF DAMAGE

  Media

WITNESSES

• WERE THERE ANY WITNESSES?

  YES

  NO

• RECORD DETAILS OF WITNESSES STATEMENT

OBSERVATIONS/CONTRIBUTING FACTORS

• OBSERVATIONS/CONTRIBUTING FACTORS

  Select Inadequate guarding Inadequate lighting Inadequate/lack of training Inadequate/lack of work procedures Exposure to electricity Use of incorrect tools/equipment Incorrect manual handling equipment Lack of supervision Exposure to chemicals/hazardous substances Exposure to sound/noise Congested Work areas/poor housekeeping Faulty equipment/materials Lack of PPE Fire/Explosion No Risk Assessments No safety equipment Other

  • Inadequate guarding
  • Inadequate lighting
  • Inadequate/lack of training
  • Inadequate/lack of work procedures
  • Exposure to electricity
  • Use of incorrect tools/equipment
  • Incorrect manual handling equipment
  • Lack of supervision
  • Exposure to chemicals/hazardous substances
  • Exposure to sound/noise
  • Congested Work areas/poor housekeeping
  • Faulty equipment/materials
  • Lack of PPE
  • Fire/Explosion
  • No Risk Assessments
  • No safety equipment
  • Other

• Provide Details:

CONCLUSIONS (include any root causes)

• CONCLUSIONS?

RECOMMENDATIONS (include any corrective, preventive actions)

• RECOMMENDATIONS?

FURTHER ACTIONS

• FURTHER ACTIONS

  Select Has the root cause been established? Is a conference call required? Is verification required at next audit? Does a Safety Alert need producing?

  • Has the root cause been established?
  • Is a conference call required?
  • Is verification required at next audit?
  • Does a Safety Alert need producing?

PHOTOGRAPHS

• PHOTOGRAPHS

  Media

REPORT COMPLETED BY

• INVESTIGATION COMPLETED BY:

  Sign

• DATE OF INVESTIGATION REPORT

  Date