Incident Notification & Investigation Report - duplicate

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Investigation Information.

• Affected/Injured Employee's Name:

• Affected/Injured Employee's Name (If more than one):

• Location of incident. (Specify site location)

• Department Manager:

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• To whom was the incident reported?

• Investigated By:

Accident (Check One Below)- Event That Resulted In Personal Injury, Vehicle or Equipment Damage

Injury/Illness (Check One) Complete Section A

• First Aid Only

• OSHA Recordable

• Lost Time

Vehicle Damage (Complete Section B)

• Damage Description:

• Damage Estimate:

• Damage Description:

• Damage Estimate:

Incident Description (initial information summary)

• List out what happened, Who, What, Where When, Why

• Immediate Actions Taken?

• Person Responsible for Immediate Actions:

Personnel Notified

• Name of Person Notified:

• Job Title of Person Notified:

• Date and Time

  Date

Photo's of Event

• Event Photos

  Media

• Event Photos

  Media

Contributing Factors

• Contributing Factors: Description why this factor contributed or caused the incident (Typically there is more than a single casual factor):

• Contributing Factors Photo

  Media

• Contributing Factors Photo

  Media

ANALYSIS

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

Corrective Actions Plan- to prevent Re-Occurrence

• Corrective Action to be Taken:

• Person Responsible for Corrective Action Plan:

• Due Date:

• Photo's of Corrected Actions

  Media

Signatures

• Affected Employee Name:

• Affected Employee Signature

  Sign

• Supervisor/Manager Name:

• Supervisor/Manager Signature

  Sign

• Safety Team Member Name:

• Safety Team Member Signature

  Sign

• Affected Employee Name (if more than one)

• Affected Employee Signature (if more than one)

  Sign

APPENDIX A- Injury Information

• Enter Name of 1st Employee Affected/Injured

• Name of Injured Employee

• Job Title of Injured Employee

• Activity being Performed

• Enter name of other employee's affected/injured (if more than one)

• Name of Affected/Injured Employee

• Job Title of Affected/Injured Employee

• Activity being Performed

• Did the employee complete a Drug and Alcohol Screen?

  Yes

  No

  N/A

• Date of Drug/Alcohol Screen

  Date

• Exposure- How the event occurred

  Select Animal Exposure Caught In Electrical Contact Explosion Fire Insect Exposure N/A Other Oxygen Deficiency Struck Against Temperature Extremes Vehicle struck Vehicle Bodily Reaction Contact with Skin Environmental Exposure Fall Inhalation Noise Exposure Object Struck Vehicle Overexertion Repetitive Motion/Ergo Struck By Vehicle Struck Object

  • Animal Exposure
  • Caught In
  • Electrical Contact
  • Explosion
  • Fire
  • Insect Exposure
  • N/A
  • Other
  • Oxygen Deficiency
  • Struck Against
  • Temperature Extremes
  • Vehicle struck Vehicle
  • Bodily Reaction
  • Contact with Skin
  • Environmental Exposure
  • Fall
  • Inhalation
  • Noise Exposure
  • Object Struck Vehicle
  • Overexertion
  • Repetitive Motion/Ergo
  • Struck By
  • Vehicle Struck Object

• Source- Object, substance, person or exposure that directly produced the event or inflicted the injury

  Select Animal Container Electrical AC Food Insect Ladder N/A Other Plant/Vegetation Solar Panel Tool-Power Walking Surface Chemical Door Electrical DC Furniture Knife Motor Vehicle Noise Person Repetitive Motion Tool-Hand Trencher Weather

  • Animal
  • Container
  • Electrical AC
  • Food
  • Insect
  • Ladder
  • N/A
  • Other
  • Plant/Vegetation
  • Solar Panel
  • Tool-Power
  • Walking Surface
  • Chemical
  • Door
  • Electrical DC
  • Furniture
  • Knife
  • Motor Vehicle
  • Noise
  • Person
  • Repetitive Motion
  • Tool-Hand
  • Trencher
  • Weather

• Body Part-Identify the part of the body affected by the injury or illness

  Select Ankle Buttock Chest Elbow Face Foot Groin Head Jaw Leg Neck Nose Stomach Thigh Throat Back Calf Ear Eye Eye Finger Finger Forearm Hand Hip Knee Mouth N/A Shoulder Teeth Toes Wrist

  • Ankle
  • Buttock
  • Chest
  • Elbow
  • Face
  • Foot
  • Groin
  • Head
  • Jaw
  • Leg
  • Neck
  • Nose
  • Stomach
  • Thigh
  • Throat
  • Back
  • Calf
  • Ear
  • Eye
  • Eye
  • Finger
  • Finger
  • Forearm
  • Hand
  • Hip
  • Knee
  • Mouth
  • N/A
  • Shoulder
  • Teeth
  • Toes
  • Wrist

• Nature of Injury-Identify the physical characteristics of injury of illness

  Select Abrasion/Scratch Animal Bite Blister Chemical Burn Crushing Dislocation Fracture Heat-Related Insect/Spider Bite or Sting N/A Puncture Sprain/Strain Thermal Burn Amputation Arc Flash Burn Bruise/Contusion Cold-Related Dermatitis Electrical Contact/Shock Heart Attack Laceration Poisoning Splinter/Foreign Body Stroke

  • Abrasion/Scratch
  • Animal Bite
  • Blister
  • Chemical Burn
  • Crushing
  • Dislocation
  • Fracture
  • Heat-Related
  • Insect/Spider Bite or Sting
  • N/A
  • Puncture
  • Sprain/Strain
  • Thermal Burn
  • Amputation
  • Arc Flash Burn
  • Bruise/Contusion
  • Cold-Related
  • Dermatitis
  • Electrical Contact/Shock
  • Heart Attack
  • Laceration
  • Poisoning
  • Splinter/Foreign Body
  • Stroke

APPENDIX B- Vehicle/Equipment Damage Information

• IF Vehicle or Equipment Damage, THEN complete next section

• Location of Accident:

• Description of Damage

• Driver/Operator's Name:

• Damage Estimate:

• Vehicle Information (if applicable)

• Year:

• Make:

• Model:

• Equipment Number/License Plate Number:

• Vehicle/Equipment Owned By?

If another vehicle is involved enter the information in the following blanks

• Name of Second Vehicle Driver/Owner

• Signature of Second Vehicle Driver/Owner

  Sign

• Statement of Second Vehicle Driver/Owner

• Vehicle Information

• Year:

• Make:

• Model:

• VIN Information:

• Insurance Information

Personnel Statement

• Affected Employee's Statement

• Employee's First and Last Name:

• Supervisor:

• Date and Time

  Date

• Incident Location

• Task at the time of Incident

• Length of Time at Current Job

• Employee's Description of the Incident:

• Affected Employee's Name:

• Affected Employee's Signature:

  Sign

• Date and Time

  Date

• Witness Name:

• Witness Signature:

  Sign

• Date and Time

  Date

• Witness Statement

Causal Factor Checklist

• Procedures

  Select Not available or inconvenient for use Difficult to use Use of the procedure was not required but should be Followed Incorrectly Change in Work found out in the field required a revised approach Excess references in procedure Details less than adequate Sequence wrong Facts wrong Situation not covered Wrong revision used

  • Not available or inconvenient for use
  • Difficult to use
  • Use of the procedure was not required but should be
  • Followed Incorrectly
  • Change in Work found out in the field required a revised approach
  • Excess references in procedure
  • Details less than adequate
  • Sequence wrong
  • Facts wrong
  • Situation not covered
  • Wrong revision used

• Work Environment

  Select Housekeeping poor Hot/Cold Lightning Noise Air Cramped Quaters

  • Housekeeping poor
  • Hot/Cold
  • Lightning
  • Noise
  • Air
  • Cramped Quaters

• Communication

  Select Verbal Communication Standard terminology not used Repeat back not used Written Communication Communication not Accurate No Communication or Untimely

  • Verbal Communication
  • Standard terminology not used
  • Repeat back not used
  • Written Communication
  • Communication not Accurate
  • No Communication or Untimely

• Equipment

  Select Design specifications less than adequate Design not to specifications Problems not anticipated Independent review less than Adquate Not disconnected properly No Preventive Maintenance (PM) PM not being conducted Defective equipment/parts

  • Design specifications less than adequate
  • Design not to specifications
  • Problems not anticipated
  • Independent review less than Adquate
  • Not disconnected properly
  • No Preventive Maintenance (PM)
  • PM not being conducted
  • Defective equipment/parts

• Management System

  Select No Standard policy or control Policy or control not strict enough Confusing/Incomplete policy or control Technical error in the policy or control Conflicting SOP's Lack of Policy/Enforment No way to implement the policy or Standard No accountability No method of implementing the Policy or Standard Infrequent audits & evaluations Inadequate Supervision No employee feedback Unclear assignment of responsibilites No reinforcement Corrective Actions less than adequate or not yet implemented

  • No Standard policy or control
  • Policy or control not strict enough
  • Confusing/Incomplete policy or control
  • Technical error in the policy or control
  • Conflicting SOP's
  • Lack of Policy/Enforment
  • No way to implement the policy or Standard
  • No accountability
  • No method of implementing the Policy or Standard
  • Infrequent audits & evaluations
  • Inadequate Supervision
  • No employee feedback
  • Unclear assignment of responsibilites
  • No reinforcement
  • Corrective Actions less than adequate or not yet implemented

• Human Engineering

  Select Labels less than adequate Arrangement/placement of Protective covers Controls less than adequate Monitoring less than adequate

  • Labels less than adequate
  • Arrangement/placement of Protective covers
  • Controls less than adequate
  • Monitoring less than adequate

• Training

  Select Training was not provided Did not attended provided training Did not understand requirements Training less than adequate

  • Training was not provided
  • Did not attended provided training
  • Did not understand requirements
  • Training less than adequate