Inglett & Stubbs Incident Investigation Form

• Document No.

• Job Site/Number

• Location/County

• Conducted on

  Date

• Prepared by

• Employees

Information about Employee

• Employee Name

• Employee Contact Information (Home address/Phone/Email):

• Male/Female

  Male

  Female

• Classification

• Date of Birth

  Date

• Date of Hire

  Date

• Electrician Work Experience (years/months):

• Death

  Yes

  No

• Date of Death

Treatment

• Was employee treated in the emergency room?

  Yes

  No

• Was employee admitted to hospital overnight?

  Yes

  No

• Address of physician/Clinic/Hospital:

• Did the employee return to work the day after the accident?

  Yes

  No

• Did the physician give work restrictions or lost time?

  Yes

  No

• Describe

Information About the Case

• Date of injury or illness

  Date

• Time Employee Began Work

  Date

• Time of Incident

  Date

• What was the employee doing just before the incident occurred? Describe activity, as well as the tools, equipment, or material the employee was using.

• What happened? Describe in detail.

• What was the injury or illness? What body part, what side, and what type of injury?

• What was the source of the accident? (what object or substance directly injured the employee? i.e concrete floor, electrical panel, screwdriver, etc...)

Employee's Description of Accident

• Describe what happened, where, when, how, and why:

• Employee Signature

  Sign

Supervisor's Description of Accident

• Describe what happened, where, when, how, and why:

Accident Cause

• Supervisor to identify unsafe acts/conditions, contributory factors, root cause(s):

Corrective Action

• Describe steps taken to prevent a reoccurence:

Signatures

• Supervisor Signature

  Sign

SEND THIS FORM TO SAFETY DIRECTOR WITHIN 24 HOURS OF THE ACCIDENT