Incident/Near Miss Investigation Form

• Conducted on

  Date

• Prepared by

Type of Occurrence

• Occupational Illness / Injury

• Property / Equipment Damage

• Near Miss

• Motor Vehicle Incident

• Theft / Vandalism

• Environmental Spill

• Public / Client Complaint

• Breach of Rule

• Other (specify):

Classification (see reference section)

• Lost Time

• Medical

• Restricted Work

• First Aid

• DAFW

• Other

MVA Ranking

• Serious

• Minor

• Not At Fault

1.0 General Information

• Business

• Country

• Region

• Incident City

• State

• Work Location

• Date and Time of Incident

  Date

• Date and Time Reported

  Date

• Reported to (Name)

Client Information

• Client Name (if applicable)

• Was Incident reported to Client?

  Yes

  No

  N/A

• Date Reported

  Date

• Client Contact (Name)

• Onsite First Aid Treatment Provided?

  Yes

  No

  N/A

• Time Reported

  Date

• Client Contact (#)

Alcohol & Drug Testing

• Was A&D testing done?

  Yes

  No

  N/A

Personal Information

• Worker Involved

• Position / Occupation

• Date of Birth (DD/MM/YY)

• Tenure

• On Duty?

  Yes

  No

  N/A

• Employee Address

• Hours on Duty (prior to incident)

• Employee Telephone

• ISS Issued Drivers Points (MVA)

Personnel Classification

• Employee

• Client Employee

• Summer Student

• Contractor

• Temporary Employee

• Third Party / Other

Task / Scope of Work Description

• Briefly describe the task being performed when incident occurred.

Incident Description

• Briefly describe how incident happened, tools, equipment or objects involved, and damages.

• Attach photographs, diagrams and additional information if required.

  Media

• Add drawing

  Drawing

• Were there witnesses?

  Yes

  No

  N/A

• Witness Name

• Witness Employer Contact Info

• See Witness Statement (see Attachment "A")
  NOTE: A copy of the Hazard Assessment, Permit(s) and Contractor Investigation Report(s) must be attached to this report.

2.0 INJURY INFORMATION - Complete section if incident resulted in or had the potential for injury.

• Was first aid given?

  Yes

  No

  N/A

• Name of First Aider

• Injured trasported to medical aid?

  Yes

  No

  N/A

• Name of Medical Facility

• Qualification of First Aid Provider

• Name of Attending Physician

• Was HSEQ Manager Notified?

  Yes

  No

  N/A

Incident contributing causes

• Airborne Particles

• Caught Between, In or On

• Chemical Exposure

• Electric Shock

• Ergonomics

• Exposure to Elements

• Fall on Same Level

• Fall to Lower Level

• Fire / Explosion

• Noise

• Noise

• Overexertion

• Overpressure

• Overstress

• Radiation

• Slips or Trips

• Smoke or Gas

• Struck By

• Struck Against

• Welding Flash

• Other (specify)

Nature of Injury (check all that are applicable)

• Abrasion

• Allergic Reaction

• Amputation

• Bite or Sting

• Burn

• Carpal Tunnel

• Contusion or Bruise

• Dermatitis / Skin Irritation

• Dislocation

• Foreign Body

• Fracture

• Frostbite / Hypothermia

• Heat Exhaustion / Stroke

• Hernia

• Inhalation

• Laceration or Cut

• Pinched Nerve

• Poisoning

• Puncture

• Sprain or Strain

• Tendonitis

• Unconscious

• Other (describe)

Body Part (check all that are applicable)

• Abdomen

• Ankle

• Arms

• Back

• Chest

• Ears

• Elbow

• Eye(s)

• Face / Jaw

• Feet / Toes

• Fingers

• Groin

• Hands

• Hips

• Knee

• Leg

• Mouth / Teeth

• Neck

• Scalp

• Shoulders

• Wrists

• Other (specify)

Location of Body Part

• Upper

• Lower

• Top

• Bottom

• Front

• Back

• Left

• Right

• Other (specify)

Medical Treatment

• Briefly describe medical treatment provided to injured person by registered Medical Practicioner; including what (if any) prescriptions were given.

Immediate Action Taken

• Actions taken to eliminate the hazard or restrict access to the hazard.

3.0 MVA / Property Damage Information - Complete section for MVAs and incidents resulting in property damage.

Vehicle or Property Damage

• Was there damage to ISS vehicle or property?

  Yes

  No

  N/A

• Is the vehicle?

  Owned

  TP Rental Agency

• Estimate to repair or replace

  < $1,500

  $1,500 - $3,000

  $3,000 - $200,000

  > $200,000

MVA Specifics

• Unit #

• Vehicle Type:

• Vehicle Speed

• Posted Speed

• Citation / Fine Issued

• DOT Commercial Vehicle

• DOT Recordable Incident

• VIN

• Police Report

  Yes

  No

  N/A

• Officer Badge #

• Officer Name:

Towed Vehicles

• Towing Company Used:

• Location of where unit was taken:

• Contact name and number:

MVA Contributing Causes

• D&A

• Distraction

• No GOAL

• No Spotter

• Fatigue

• Road Conditions

• Vehicle Condition

• Contributing Factors - Speed

• High Winds

• Poor Visibility

• Failure to Signal

• Weather Conditions

• Unauthorized Driver

• Failure to Check Mirrors

• Other (specify)

Diagram / Pictures of Accident Scene

• Provide POV or layout of the accident scene

  Drawing

• Add media

  Media

Other Parties, Vehicle, or Property Damage

• Was there damage to another parties, vehicle, or property?

  Yes

  No

  N/A

• Estimate of damage

• Other Party Name:

• Phone #

• Other Party Address:

• Insurance Provider:

• Insurance Policy #

• Insurance Claim #

• Other Info:

• Briefly describe other parties' damages

Equipment Involved

• Unit #

• Type of Unit:

• Description of Company Damages

• Photos of Company Damages

  Media

• NOTE: ISS HSEQ Manager must be notified within 24 hours and Police Report(s) must be attached to this report.

4.0 Root Cause Analysis - Complete section if incident resulted in or had the potential for injury.

Immediate / Direct Causes - Check all that apply

Substandard Acts - What action happened immediately prior to the incident?

• Operating equipment without authority

• Failure to warn

• Failure to follow procedures or standards

• Operating at an improper speed

• Removing / making safety devices inoperable

• Using defective equipment / tools

• Failing to use PPE properly

• Improper loading (mechanical / manual)

• Improper placement

• Improper manual lifting or carrying

• Unsafe position (i.e. in the line of fire)

• Servicing equipment in operation

• Trying to save or gain time

• Inattentive to job hazards

• Horseplay

• Other (specify)

• Provide supporting comments for choices above - Substandard Acts / Practices

Substandard Conditions - What conditions were present that contributed to the incident?

• Inadequate guards or barriers

• Inadequate or improper protective equipment

• Defective tools, equipment, or materials

• Fire and explosion hazards

• Noise exposure

• Inadequate or excess illumination

• Inadequate Ventilation

• High or Low temperature exposure

• Hazardous environmental conditions (gases, dust, fumes, mists)

• Congested work area

• Insufficient housekeeping

• Poor Weather Condition

• High winds

• Other (specify)

• Provide supporting comments for choices above - Substandard Conditions

Contributing Causes - Check all that apply

Personal Factors - What factors contributed to the incident?

• Improper motivation

• Inadequate decision-making capabilities

• Inadequate physical capabilities

• Lack of knowledge

• Lack of skill

• Physical stress

• Mental stress

• Abuse or misuse

• Other (specify)

• Provide supporting comments for choices above - Personal Factors

Job / System Factors

• Improper communication

• Inadequate engineering

• Inadequate leadership and/or supervision

• Inadequate maintenance

• Inadequate purchasing

• Inadequate tools / equipment / materials

• Inadequate work standards / procedures

• Excessive wear and tear

• Other (specify)

• Provide supporting comments for choices above - Job / System Factors

Analysis of Incident

• Preventive Action - What are recommendations to prevent reocurrence?

Click to add Action Items

• Action Items

• Assigned to

• Completion Date

  Date

• Name of Lead Investigator

  Sign

• Title

• Date:

  Date

• Supervisor Comments

• Name - ISS Supervisor

  Sign

• Select date

  Date

5.0 Management Review - Complete section if incident resulted in or had the potential for injury.

• Comments

Corrective Actions

• Leadership and Administration

• Leadership Training

• Planned Inspections & Maintenance

• Critical Task Analysis & Procedures

• Incident Investigation

• Task Observation

• Emergency Preparedness

• Rules & Work Permits

• Incident Analysis

• Knowledge & Skill Training

• Personal Protective Equipment

• Health & Hygiene Control

• System Evaluation

• Engineering & Change Management

• Personal Communications

• Group Communications

• General Promotions

• Hiring & Placement

• Materials & Services Management

• Off-the-Job Safety

• Environmental Management

• Quality Management

• Supporting comments for choices above:

Action Items

Click to add Action Items

• Action Items

• Assigned to

• Completion Date

  Date

• Name - ISS Management

  Sign

• Select date

  Date

Witness Statement

• Name:

• Phone #

• Occupation:

• Employer:

• Employer Phone #

• Employer Address:

• Briefly but concisely outline sequence of events that were before, during, and after incident.

• Signature

  Sign

• Select date

  Date

• 6.0 Risk Analysis And Reference Material