Incident Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Accident Overview

Employee Information

• Date & Time of Incident:

  Date
• Accident Location:
  Address

• Foreman's/Supervisor's Name:

• Employee Classification:

  Permanent

  Temporary

Accident Overview

• Damage Type:

  Select Utility Property Third Party Property TBD

  • Utility Property
  • Third Party Property
  • TBD

• Personal Injury:

  Select Near Miss Accident Loss Incurred

  • Near Miss
  • Accident
  • Loss Incurred

• Injury / Illness:

  Select First Aid Medical Treatment Saw Doctor

  • First Aid
  • Medical Treatment
  • Saw Doctor

• Vehicle Incident:

  Select Preventable Non-Preventable Police Present

  • Preventable
  • Non-Preventable
  • Police Present

• Brief Description of the Sequence of Events & Extent of Injury/Damage:

• Was there a written or verbal safety rule or procedure for the activity involved?

  Yes

  No

  N/A

• If yes, what is the number or paragraph?

Section I: Overview of Events:

• Select date

  Date

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  Date

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  Date

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  Date

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  Date

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  Date

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  Date

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  Date

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  Date

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  Date

Section II: Personal Injury or Near Miss:

Type of Event:

• Details:

  Select Struck Against (Running/Bumping) Struck By (Hit By Moving Object) Fall From Elevation To Lower Level Fall On Same Level (Slip/Trip/Fall) Caught In (Pinch/Nip) Caught On (Snagged/Hung) Caught Between Crush/Amputated) Poison Oak Foreign Body Cut/Laceration Fracture Contact With (Electricity/Heat/Cold/Radiation) Abnormal Operation Product Contamination Over-Stress/Pressure/Exert/Ergo Equipment Failure Environmental Release/Exposure (Heat/Cold) Animal Bite Sprain/Strain Abrasion/Bruise Other

  • Struck Against (Running/Bumping)
  • Struck By (Hit By Moving Object)
  • Fall From Elevation To Lower Level
  • Fall On Same Level (Slip/Trip/Fall)
  • Caught In (Pinch/Nip)
  • Caught On (Snagged/Hung)
  • Caught Between Crush/Amputated)
  • Poison Oak
  • Foreign Body
  • Cut/Laceration
  • Fracture
  • Contact With (Electricity/Heat/Cold/Radiation)
  • Abnormal Operation
  • Product Contamination
  • Over-Stress/Pressure/Exert/Ergo
  • Equipment Failure
  • Environmental Release/Exposure (Heat/Cold)
  • Animal Bite
  • Sprain/Strain
  • Abrasion/Bruise
  • Other

• Event Details Explanation:

Part of Body Affected:

• Details:

  Select Scalp Shoulder Skull Upper Arm Neck Elbow Ears Forearm Eyes Wrist Mouth Hand Teeth Finger(s) Face Upper Back Lower Back Thigh Lower Leg Chest Knee Abdomen Foot Hip Toe(s) Groin Ankle Side Other

  • Scalp
  • Shoulder
  • Skull
  • Upper Arm
  • Neck
  • Elbow
  • Ears
  • Forearm
  • Eyes
  • Wrist
  • Mouth
  • Hand
  • Teeth
  • Finger(s)
  • Face
  • Upper Back
  • Lower Back
  • Thigh
  • Lower Leg
  • Chest
  • Knee
  • Abdomen
  • Foot
  • Hip
  • Toe(s)
  • Groin
  • Ankle
  • Side
  • Other

• Affected Body Part Explanation:

Personal Protective Equipment:

• Details:

  Select Hard Hat Work Boots Safety Glasses Gloves Hearing Protection Harness High Visibility Seatbelt Rubber Gloves Personal Grounds Cover FR Clothing Not Available Not Required Other

  • Hard Hat
  • Work Boots
  • Safety Glasses
  • Gloves
  • Hearing Protection
  • Harness
  • High Visibility
  • Seatbelt
  • Rubber Gloves
  • Personal Grounds
  • Cover
  • FR Clothing
  • Not Available
  • Not Required
  • Other

• Personal Protective Equipment Explanation:

Immediate / Direct Causes

• Substandard Act(s) Details:

  Select Operating Equipment W/out Authority/Training Failure To Warn Failure To Secure Operating At Improper Speed Making Safety Devices Imperative Using Defective Equipment Failing To Use PPE Properly Improper Loading of Equipment/Materials Improper Placement Improper Lifting Improper Position For The Task Servicing Equipment In Operation Horseplay Under Influence of Alcohol/Other Drugs Using Equipment Improperly Failure To Follow Procedure/Policy/Practice Failure To Identify Hazard/Risk Failure To Check/Monitor Failure To React/Correct Failure To Communicate/Coordinate Other

  • Operating Equipment W/out Authority/Training
  • Failure To Warn
  • Failure To Secure
  • Operating At Improper Speed
  • Making Safety Devices Imperative
  • Using Defective Equipment
  • Failing To Use PPE Properly
  • Improper Loading of Equipment/Materials
  • Improper Placement
  • Improper Lifting
  • Improper Position For The Task
  • Servicing Equipment In Operation
  • Horseplay
  • Under Influence of Alcohol/Other Drugs
  • Using Equipment Improperly
  • Failure To Follow Procedure/Policy/Practice
  • Failure To Identify Hazard/Risk
  • Failure To Check/Monitor
  • Failure To React/Correct
  • Failure To Communicate/Coordinate
  • Other

• Substandard Act(s) Explanation:

• Substandard Condition(s) Details:

  Select Inadequate Guards/Barriers Inadequate/Improper Protective Equipment Defective Tools, Equipment or Materials Congestion/Restricted Action Inadequate Warning System Fire & Explosion Hazards Poor Housekeeping/Disorder Noise Exposure Radiation Exposure Temperature Extremes Inadequate/Excess Illumination Inadequate Ventilation Presence of Harmful Materials Inadequate Instructions/Procedures Inadequate Information/Data Inadequate Preparation/Planning Inadequate Support/Assistance Inadequate Communication Road Conditions Other

  • Inadequate Guards/Barriers
  • Inadequate/Improper Protective Equipment
  • Defective Tools, Equipment or Materials
  • Congestion/Restricted Action
  • Inadequate Warning System
  • Fire & Explosion Hazards
  • Poor Housekeeping/Disorder
  • Noise Exposure
  • Radiation Exposure
  • Temperature Extremes
  • Inadequate/Excess Illumination
  • Inadequate Ventilation
  • Presence of Harmful Materials
  • Inadequate Instructions/Procedures
  • Inadequate Information/Data
  • Inadequate Preparation/Planning
  • Inadequate Support/Assistance
  • Inadequate Communication
  • Road Conditions
  • Other

• Substandard Condition(s) Explanation:

• Basic/Root Causes - Job/System Factors

  Select Inadequate Leadership and/or Supervision Inadequate Purchasing Inadequate Tools/Equipment Excessive Wear & Tear Inadequate Engineering Inadequate Maintenance Inadequate Work Standards Inadequate Communications Other

  • Inadequate Leadership and/or Supervision
  • Inadequate Purchasing
  • Inadequate Tools/Equipment
  • Excessive Wear & Tear
  • Inadequate Engineering
  • Inadequate Maintenance
  • Inadequate Work Standards
  • Inadequate Communications
  • Other

• Basic/Root Causes - Job/System Factors Explanation:

Section III: Vehicle Incident

Event Details:

• Were there injuries to either party?

  Yes

  No

  N/A

• Was the vehicle 26,000 lbs. or bigger?

  Yes

  No

  N/A

• Did the accident happen off the driven roadway?

  Yes

  No

  N/A

• Did the incident happen on the driven roadway?

  Yes

  No

  N/A

• Was there damage to the utility vehicle?

  Yes

  No

  N/A

• Was an insurance report filed?

  Yes

  No

  N/A

• Was a DMV report filed?

  Yes

  No

  N/A

• Was a DOT report filed?

  Yes

  No

  N/A

• Was an enforcement agency present and conducting an investigation?

  Yes

  No

  N/A

• Was substance testing performed?

  Yes

  No

  N/A

• Did the driver have a current CDL and medical card?

  Yes

  No

  N/A

• Explanation of Vehicle Incident:

Impact of Accident

• Collision with vehicle moving the same direction

  Yes

  No

  N/A

• Running into/sideswiping stationary vehicle

  Yes

  No

  N/A

• Running into/sideswiping object at roadside

  Yes

  No

  N/A

• Struck by vehicle while stationary on roadway

  Yes

  No

  N/A

• Struck by vehicle while stationary off roadway

  Yes

  No

  N/A

• Other non-collision accidents

  Yes

  No

  N/A

• Collision with vehicle moving in opposite direction

  Yes

  No

  N/A

• Struck pedestrian

  Yes

  No

  N/A

• Backing into object or vehicle

  Yes

  No

  N/A

• Damage by object in roadway

  Yes

  No

  N/A

• Mechanical failure

  Yes

  No

  N/A

• Struck by object falling from another vehicle

  Yes

  No

  N/A

• Collision involving animal

  Yes

  No

  N/A

• Collision involving pedal cycle

  Yes

  No

  N/A

• Collision w/vehicle moving in perpendicular direction

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Explanation of Impact of Accident:

Contributing Factors

• Following too closely

  Yes

  No

  N/A

• Failure to signal intentions

  Yes

  No

  N/A

• Speed too fast for conditions

  Yes

  No

  N/A

• Disregarded traffic signals/signs

  Yes

  No

  N/A

• Improper passing

  Yes

  No

  N/A

• Improper turning

  Yes

  No

  N/A

• Improper backing

  Yes

  No

  N/A

• Failure to leave sufficient room

  Yes

  No

  N/A

• Failure to check cross traffic

  Yes

  No

  N/A

• Pulled out into oncoming traffic

  Yes

  No

  N/A

• Driver violated DMV rules/laws

  Yes

  No

  N/A

• Driver used poor judgement

  Yes

  No

  N/A

• Improper lane change

  Yes

  No

  N/A

• Improper parking

  Yes

  No

  N/A

• Explanation of Contributing Factors:

Diagrams & Pictures:

• Pictures:

  Media

• Diagrams:

  Drawing

• Comments:

List Of Employees/Witnesses Interviewed:

• Name:

• Title:

• Contact Information:

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• Contact Information:

Conclusions:

• Findings should concisely summarize the "what", "why" and "fix it" with future expectations.

• Supervisor's Findings:

• Supervisor's Signature:

  Sign

• Date of Signature:

  Date

• Manager's Findings:

• Manager's Signature:

  Sign

• Date of Signature:

  Date

• Investigator's Findings:

• Investigator's Signature:

  Sign

• Date of Signature:

  Date

Safety Committee Review:

• Safety Committee Recommendations:

• Safety Committee Chairman:

• Safety Committee Chairman Signature:

  Sign

• Date of Signature:

  Date

• Recommendation Completed By:

• Signature:

  Sign

• Date of Signature:

  Date