Information
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Conducted on
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Prepared by
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Incident Location (physical address )
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Department
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First Aid
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Medical Only
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Action Required: Complete the Investigation within 24 Hours and Email Safety Team
Identification Information
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Name
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Date and time of incident/near miss
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Department
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Occupation/job title
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Date of hire
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Supervisor(s) on duty
- Joe Atchley, GM
- Craig Rathgeb, Dir of Ops
- Tim Gream, Maintenance Supervisor
- Jason Richey, EHSS
- Other
Supplementary Information
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Location of incident/near miss
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On premises?
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Department where incident/near miss occurred
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Was injured/involved person(s) performing regular job duties at time of incident?
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Time shift started
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Overtime?
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Type of injury/illness
- First Aid only (at MRS)
- Ambulatory
- Post injury treatment
- Emergency Medical
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Name/Address of Medical Facility
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Was injured admitted for overnight hospital stay? If yes, state location of hospital if not initial treating facility
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Did injury result in death? If yes, state date of death
Investigation/Analysis
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Nature of injury and affected body part
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Describe property damage
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Location where incident occurred
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Task being conducted
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Employee Task
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Materials/equipment used
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Preceding situation/event
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List all individuals involved
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Involved Employee Statement/description of events
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Involved Employee Statement/description of events
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Involved Employee Statement/description of events
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Involved Employee Statement/description of events
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Involved Employee Statement/description of events
Machinery/Equipment involved
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Was equipment or machinery involved? If yes list specific equipment, ID #, and any other pertinent information<br>
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Age
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Functions of Equipment
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Has equipment been modified? If yes, when?<br>
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Was there any mechanical failure? If yes, explain
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Is firm General or Subcontractor?
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If yes, date of contract
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List any weather conditions which may have contributed to incident
Training
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Did employee receive specific training or instructions relating to safety and health on job being performed?<br>
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Type
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Instructed by
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Date of last refresher training
Personal Protective Equipment
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Did employee use appropriate PPE for the job/task performed?
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Did equipment fail? If so, describe
Corrective Actions
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Were any corrective or preventative actions taken due to the incident?
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If yes, what specific actions? If no, why?
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Is retraining required?<br>
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Is disciplinary action required? If yes, state action taken
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Date/time corrective actions completed
Management/Administrative actions
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Did incident result in an OSHA recordable injury? If yes, have all appropriate personnel been notified?
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Scott Bichel, Director of Manufacturing Services
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Joe Atchley, Plant GM
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Craig Rathgeb, Director of Operations
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Jason Richey, EHSS Coordinator
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Lisa Ripper, Human Resources Coordinator
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Has incident been reported to insurance company (Zurich)?<br>All incidents requiring post incident treatment outside of first aid on site should be reported to insurance. <br>
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Is any further action required? If yes, state action to be taken
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Is unsafe condition eliminate or mitigated to prevent future unsafe acts or conditions from occurring?
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Is Plant management satisfied with plan of action and investigation
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Joe Atchley, Plant GM (required)
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Jason Richey, EHSS Coordinator
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Craig Rathgeb, Director of Operations
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Involved employee (signature required if disciplinary action of any kind to include verbal warnings is rendered)
