Incident/Injury Report Form

• Document No.

• Date and time incident occurred

  Date
• Where did the incident Occur?
  Address

• District/Yard EE assigned

  Select Charlotte Kermit Monahans Orla Stockdale Nitrogen Stockdale Office/Admin Crude Long Haul

  • Charlotte
  • Kermit
  • Monahans
  • Orla
  • Stockdale
  • Nitrogen
  • Stockdale Office/Admin
  • Crude Long Haul

Personal and Incident Details

• Employee's Name

• Date of Birth

• Sex

  Male

  Female

• Occupation

  DRIVER

  MECHANIC

  OFFICE/ADMIN

  SUPERVISOR

• Contact number

• Home address

• Supervisor

  Select Don Shaw Earnest Watson Edward Johnson Jeff Guy Jorge Gomez Troy Pruitt Kurt Grandshire Ralph Brunt Mike Yow Richard Jimenez Sly torres Joe HIll Rudy Espinosa Art Gunn Gonzalo Navarro Mike Almaraz Ron Brownridge Derrell Hardison

  • Don Shaw
  • Earnest Watson
  • Edward Johnson
  • Jeff Guy
  • Jorge Gomez
  • Troy Pruitt
  • Kurt Grandshire
  • Ralph Brunt
  • Mike Yow
  • Richard Jimenez
  • Sly torres
  • Joe HIll
  • Rudy Espinosa
  • Art Gunn
  • Gonzalo Navarro
  • Mike Almaraz
  • Ron Brownridge
  • Derrell Hardison

Injury Details

• Type of injury or disease (e.g burn)

• Part/s of the body affected

• Date and Time of symptoms (if different than time of incident)

  Date

• Was medical treatment refused?

  YES

  NO

  N/A

• Was medical treatment given?

  YES

  NO

  N/A

• Describe treatment given. Note any medications, if prescribed

• Name and phone number of treatment provider

• Date and time treatment received

  Date

• Time lost due to injury?

  Yes

  No

• How many hours/days, based on information available?

• How did the injury happen?

• List any witnesses

Investigation

• How long had EE been working prior to the incident?

• How long had EE been working on this task?

• Is this task part of EEs normal duties?

  Yes

  No

  N/A

• Has EE been trained for this task?

  Yes

  No

  N/A

• What was EE doing in the time prior to the incident?

• Are there any other factors involved (e.g management, work environment, equipment) involved?

• What do you think could have been done to prevent this from occuring?

• Other comments or observations

• Was the injury from a Slip, Trip or Fall (STF)

  Yes

  No

• Surface Type

  Select Cement Tile Grass Sand Footpath Carpet Gravel Rocks Road Dry Wet Torn Damaged Other

  • Cement
  • Tile
  • Grass
  • Sand
  • Footpath
  • Carpet
  • Gravel
  • Rocks
  • Road
  • Dry
  • Wet
  • Torn
  • Damaged
  • Other

• Type of shoes?

  Select Open Close Boots High Heels Sandals None Other

  • Open
  • Close
  • Boots
  • High Heels
  • Sandals
  • None
  • Other

• Height of Fall (if fall was on level surface, state accordingly)

• What was EE doing at time of fall?

  Running

  Walking

  Turning a corner

  Jumping

• If stairs involved

  Going up

  Going down

  N/A

• EE fell on ?

  Back

  Front

  Side

• State if EE was carrying any objects. (i.e. what was the object carried, how carried - left hand, right hand, both hands, etc.)

• Equipment/objects involved?

  Yes

  No

• Equipment in good condition?

  Yes

  No

  N/A

• Date of last service of equipment

  Date

• Appropriate safety equipment used?

  Yes

  No

  N/A

• Lighting adequate?

  Yes

  No

  N/A

• Housekeeping issues contributed?

  YES

  NO

  N/A

• Workload excessive?

  YES

  NO

  N/A

• Workload repetitive?

  YES

  NO

  N/A

• Does it involve manual material handling?

  Yes

  No

  N/A

• What was EE doing?

  Running

  Walking

  Turning a corner

  Jumping

• Were the items within easy reach?

  Yes

  No

  N/A

• Ergonomic equipment available?

  Yes

  No

  N/A

• Was the ergonomic equipment being used correctly?

  Yes

  No

  N/A

• Repetitive and forceful movements used?

  Yes

  No

  N/A

• Action involved

  Select Reaching Bending Stooping Sitting Kneeling Twisting Pulling Pushing Lifting Catching Lowering Carrying

  • Reaching
  • Bending
  • Stooping
  • Sitting
  • Kneeling
  • Twisting
  • Pulling
  • Pushing
  • Lifting
  • Catching
  • Lowering
  • Carrying

• Weight of object

• Distance carried/position of object moved from/to

• Height of load

Pictures / Documents / Drawings

• Add media

  Media

• Add media

  Media

For the General Manager

• OSHA RECORDABLE

  Yes

  No

• Comments and Observation

• Recommendation

  Select Elimination of the task Substition or another way of doing the task Engineer a way to make the job safer Administration or improve work practices Personal Protective Equipment OTHER

  • Elimination of the task
  • Substition or another way of doing the task
  • Engineer a way to make the job safer
  • Administration or improve work practices
  • Personal Protective Equipment
  • OTHER

• Person assigned

• Target Date

  Date

Supervisor Signature

• Supervisor

  Sign