INCIDENT INVESTIGATION REPORT

• Document No.

• Berry Bros.

• Client / Site

• Clients Address

• Location
  Address

• Conducted on

  Date

EMPLOYEE INFORMATION

• Name of Injured:

• Employee ID #:

• Social Security Number:

• Sex:

  Select Male Female

  • Male
  • Female

• Age:

• Home Address:

• Employee's usual occupation:

• Occupation at time of incident:

• Employment category:

  Select Regular, Full Time Regular, Part Time Non-Employee Temporary Seasonal

  • Regular, Full Time
  • Regular, Part Time
  • Non-Employee
  • Temporary
  • Seasonal

• Length of employment:

  Select Less than 1 month 1-5 months 6 months - 5 years Over 5 years

  • Less than 1 month
  • 1-5 months
  • 6 months - 5 years
  • Over 5 years

• Time in occupation at time of incident:

  Select Less than 1 month 1-5 months 6 months - 5 years Over 5 years

  • Less than 1 month
  • 1-5 months
  • 6 months - 5 years
  • Over 5 years

INJURY / PHYSICIAN INFORMATION

• Nature of injury and part of body:

• Case numbers/names of others injured in same incident:

• Name and address of physician:

• Name and address of hospital:

• Date and Time of incident:

  Date

• Severity of injury:

  Select Fatality Lost workdays-days away from work Lost workdays-days of restricted activity Medical treatment needed First aid needed Other

  • Fatality
  • Lost workdays-days away from work
  • Lost workdays-days of restricted activity
  • Medical treatment needed
  • First aid needed
  • Other

• Specify if other:

• Was injured drug tested:

  YES

  NO

• On employers premises:

  Select YES NO

  • YES
  • NO

• Phase of employee's workday at time of injury:

  Select During rest period During meal period Working overtime Entering or leaving facility Performing work duties Other

  • During rest period
  • During meal period
  • Working overtime
  • Entering or leaving facility
  • Performing work duties
  • Other

• Specify if other:

INCIDENT DESCRIPTION:

• Describe how incident occurred:

• Photos of incident:

  Media

• Drawings of incident:

  Drawing

INCIDENT SEQUENCE:

• Describe, in reverse order of occurrence, events preceding the injury and incident. Starting with the injury and moving backward in time, reconstruct the sequence of events that led to the injury.

• Injury event:

• Incident event:

• Preceding event # 1:

• Preceding event # 2:

• Preceding event # 3, ect.:

TASK AND ACTIVITY AT TIME OF INCIDENT:

• General type of task:

• Specific activity:

• Employee was working:

  Select Alone With crew or fellow worker Other

  • Alone
  • With crew or fellow worker
  • Other

• Specify if other:

• Posture of employee:

• Supervision at time of incident:

  Select Directly supervised Not supervised Indirectly supervised Supervision not feasible

  • Directly supervised
  • Not supervised
  • Indirectly supervised
  • Supervision not feasible

CAUSAL FACTORS:

• Events and conditions that contributed to the incident. Include actions identified using the Guide for Identifying Causal Factors and Corrective Actions.

• List Causal Factors:

CORRECTIVE ACTIONS:

• Those that have been or will be taken taken to prevent recurrence. Include actions identified using the guide for identifying Causal Factors and Corrective Actions.

• List Corrective Actions:

Approval Signatures:

• Prepared By:

  Sign

• Title:

• Department:

• Date:

  Date

• Approved By:

  Sign

• Title:

• Date:

  Date

• Approved By:

  Sign

• Title:

• Date:

  Date