Incident Report

• Document No.

Incident Description

• Short Incident Description

• Employee Incident Report

• Site

• Conducted on

  Date

• Prepared by

• Location
  Address

Project/Incident Site

• Job Number and Name of Project Where Incident Occurred

• Lead Supervisor/Manager on Site

• Phone Number of Lead Supervisor/Manager on Site

• Current Amount of Employees OnSite

Incident Investigation

• What type of incident occurred?

  Select Spill Near Miss Property/Equipment Damage Injury Other

  • Spill
  • Near Miss
  • Property/Equipment Damage
  • Injury
  • Other

• Name of Injured Employee

• Classification/Job Title of Injured Employee

• Date that Injured Employee was Hired

  Date
• Home Address of Injured Employee
  Address

• Home Telephone Number

• Mobile Telephone Number

• Date & Time of incident

  Date

• Date & Time employee began work

  Date

• Describe injury and parts of body affected

• What object/substance directly injured the employee

• Injured Employee: State in your own words description of pain/discomfort and location of injury.

• Pain from scale 1-10

• Was notified?

  Yes

  No

  N/A

• Provide reason why

• Was on-site first aid treatment given?

  Yes

  No

• Who administered first aid?

• What first aid was performed? (ice, bandage, anti-bacterial cream, etc.)

• Was employee transported to hospital or other medical provider?

  Yes

  No

• Name of hospital or medical provider

• Was employee transported by ambulance?

  Yes

  No

• Where did the accident happen and who was involved? Provide a full description of the surroundings of the location and the individuals involved.

• What was happening at the time of the accident and why was it taking place?

• What were the events leading up to the accident? Describe the sequence in order and when they took place.

• Has the employee performed the task before?

  Yes

  No

• How many times and what training have they received pertaining to the task?

• Photograph of certification (if available)

  Media

• Have they received training in order to perform the task?

  Yes

  No

• List training employee has received

• Photograph of certification (if available)

  Media

• List name of supervisor

• Was there any equipment involved?

  Yes

  No

• Describe equipment (provide detail, including serial numbers where available)

• Were there any tools involved?

  Yes

  No

• Describe tools used (provide detail, including serial numbers where available)

• Has the injured employee ever injured this body part in the past?

  Yes

  No

  N/A

• Photographic Evidence

  Media

• Sketch/diagram of incident scene

  Drawing

• Add Property/Equipment

Item

• List Property/Equipment Damaged (list model number and serial number if available)

• Estimated value of equipment or property.

• Were any MECO personnel responsible for the operation of any equipment damaged?

  Yes

  No

• Add Name

Individual

• Employee Name

• Has employee received training in operation of equipment?

  Yes

  No

• List training

• Photograph of certification (if available)

  Media

• Name of employee's supervisor

• Investigator: Describe the nature of the damaged property or equipment. What was damaged? To what extent? Is the equipment operable? Does it pose additional risk to operators in it's current state?

• Photographic Evidence

  Media

• Sketch/diagram of incident scene

  Drawing

• What material spilled?

• Approximately how much material spilled?

  <5 gal

  5-25 gal

  25-100 gal

  100+ gal

• Did the spill enter a local waterway?

  Yes

  No

• Has this been reported to the EPA?

  Yes

  No

  N/A

• Investigator: Briefly describe how the spill occurred

• Photographic Evidence

  Media

• Sketch/diagram of incident scene

  Drawing

• Describe the near-miss incident. Investigator: enter names of people involved with near-miss in the witness area of form.

• Describe the incident

• Were safeguards or safety equipment provided?

  Yes

  No

• What safeguards or safety equipment was provided?

• Were safeguards or safety equipment used?

  Yes

  No

• What safeguard or which safety equipment was not used?

Witness Statement

• Add Witness

Witness

• Witness Name

• Classification/Job Title

• Telephone Number

• Date and Time of incident

  Date

• Location where incident occurred.

• Describe what you saw.

• Who or what caused the incident?

• In your opinion what body parts were injured?

• Was there anything that could have been done to prevent injury?

  Yes

  No

• What could have been done?

• Did anything appear suspicious about the incident?

  Yes

  No

• What was suspicious?

• Witness signature

  Sign

Root Cause Analysis (5 Why's)

• Why?

Why

• Question

• Answer

• What is the root cause of this incident?

Findings

• After review of all facts, what was the hazardous condition, unsafe work practice, or other causal factors (procedure, equipment, people and environment) that contributed to the incident?

Corrective Action

• What is recommended to prevent this type of incident from occurring again?

• Action taken to ensure recommendations are considered

• Date by which all corrective measures will be implemented

  Date

• Signature of supervisor responsible for corrections

  Sign

Finalization

• Preparer's signature

  Sign