Incident Investigation

• Employee Involved In Incident:

• Investigation conducted on:

  Date

• Prepared by:

Incident Investigation

• Incident type:

  Select Injury Vehicle Accident Property Damage Near Miss Only

  • Injury
  • Vehicle Accident
  • Property Damage
  • Near Miss Only

Vehicle Damage

• Description of vehicle damage:

• Where other vehicles involved in the accident?

  Yes

  No

  N/A

• Name and contact information of other driver:

• Description of damage to other vehicle:

• Was the other driver or passengers injured?

  Yes

  No

• Photos of: * Accident scene (360 degree view surrounding scene) * Vehicle positions following accident * Damage to company vehicle * Damage to other vehicles involved * Other driver's license plate * Other driver's proof of insurance * Other driver's vehicle registration

  Media

Property Damage

• Damaged equipment is owned by:

  Company

  Other contractor on site

  Customer/property owner

  Member of the public

  Rental company

• Name and phone number of damaged property owner:

• Description of property damage:

• Photos of property damage:

  Media

Nature of Injury

• Body parts injured:

  Select Head Neck Shoulder - Left Shoulder - Right Arm - Left Arm - Right Hand - Left Hand - Right Chest Abdomen Back Leg - Left Leg - Right Knee - Left Knee - Right Foot - Left Foot - Right Other

  • Head
  • Neck
  • Shoulder - Left
  • Shoulder - Right
  • Arm - Left
  • Arm - Right
  • Hand - Left
  • Hand - Right
  • Chest
  • Abdomen
  • Back
  • Leg - Left
  • Leg - Right
  • Knee - Left
  • Knee - Right
  • Foot - Left
  • Foot - Right
  • Other

• Please list other body parts injured.

• Injury type:

  Select Strain (pulled muscle) Sprain (injured joint) Contusion (impact, struck-by, bruise, smashed finger, etc.) Laceration Electric shock Chemical exposure Heat stress Cold stress Allergic reaction Other

  • Strain (pulled muscle)
  • Sprain (injured joint)
  • Contusion (impact, struck-by, bruise, smashed finger, etc.)
  • Laceration
  • Electric shock
  • Chemical exposure
  • Heat stress
  • Cold stress
  • Allergic reaction
  • Other

• Injury description:

• Employee involved in incident (name and job title):

• Employee Supervisor:

• Incident location:

• Date and time of incident:

  Date

• Date and time incident was reported to supervisor:

  Date

Witnesses

• Did anyone witness the incident?

  Yes

  No

• Name and phone number of witness:

• What was witnessed?

  Select Witness saw the incident Witness heard the incident Witness saw the result of the incident

  • Witness saw the incident
  • Witness heard the incident
  • Witness saw the result of the incident

• Did anyone else witness the incident?

  Yes

  No

• Name and phone number of witness:

• What was witnessed?

  Select Witness saw the incident Witness heard the incident Witness saw the result of the incident

  • Witness saw the incident
  • Witness heard the incident
  • Witness saw the result of the incident

• Did anyone else witness the incident?

  Yes

  No

• Name and phone number of witness:

• What was witnessed?

  Select Witness saw the incident Witness heard the incident Witness saw the result of the incident

  • Witness saw the incident
  • Witness heard the incident
  • Witness saw the result of the incident

General Analysis - Please include photos if possible

• SUMMARY - Describe the incident. What happened?

• INCIDENT ANALYSIS - Describe conditions that led to the incident (environmental conditions, tools/equipment used, task being performed).

• Photos of the accident scene, site conditions, and any tools or equipment involved.

  Media

Root Cause Analysis - Direct Causes - Please explain any "YES" response.

• Did employee have the authority to perform the task or operate equipment?

  Yes

  No

  N/A

• Was the equipment being used properly?

  Yes

  No

  N/A

• Where tools or equipment free from defects?

  Yes

  No

  N/A

• Where proper guards or barriers in place?

  Yes

  No

  N/A

• Where all safety devices (interlocks, fall protection) in place?

  Yes

  No

  N/A

• Was the employee operating at an appropriate speed?

  Yes

  No

  N/A

• Was the equipment loaded within its rated capacity?

  Yes

  No

  N/A

• Was the equipment shut down before it was serviced?

  Yes

  No

  N/A

• Was the employee wearing the required PPE?

  Yes

  No

  N/A

• Was the PPE being worn properly?

  Yes

  No

  N/A

• Was the PPE appropriate for the task?

  Yes

  No

  N/A

• Was site housekeeping adequate?

  Yes

  No

  N/A

• Where all company safety rules being followed?

  Yes

  No

  N/A

• Was ventilation adequate?

  Yes

  No

  N/A

• Where ground conditions safe (soft ground, uneven ground, water, mud, snow, ice, etc.)

  Yes

  No

  N/A

• Are drugs or alcohol suspected?

  Yes

  No

Underlying Causes

• Was employee supervision adequate?

  Yes

  No

  N/A

• Did the employee know how to perform the task?

  Yes

  No

  N/A

• Did the employee have adequate experience in performing the task?

  Yes

  No

  N/A

• Were tools and equipment properly maintained?

  Yes

  No

  N/A

• Did the employee have the proper tools for the task?

  Yes

  No

  N/A

• Was employee subject to physical stress due to fatigue, excessive heat, excessive cold, or excessive physical exertion?.

  Yes

  No

• Was the employee subject to mental stress due to pressure to meet deadline, pressure to save money, peer pressure, etc.?

  Yes

  No

• Any other information relevant to this incident?

  Yes

  No

  N/A

Recommendations

• Recommendations to prevent this type of accident from happening again:

Illustrations of the scene, task, equipment or other factors to better explain the incident:

• Add drawing

  Drawing

Investigation Completion

• Signature of supervisor conducting investigation:

  Sign

• Signature of employee involved in incident (if available):

  Sign