Injury, Accident, Incident Report

• Audit Title:

• Document No.

• Job Site Name:

• Job Site Address:
  Address

• Job Site Foreman's Name:

• Date of Report:

  Date

• Prepared By:

SECTION I - INCIDENT INFORMATION

• Employee's Name:

• Employee's Position:

  Select Laborer Operator Truck Driver Mechanic Iron Worker Carpenter Pipe Layer Form Setter Concrete Finisher Supervision Office Personnel

  • Laborer
  • Operator
  • Truck Driver
  • Mechanic
  • Iron Worker
  • Carpenter
  • Pipe Layer
  • Form Setter
  • Concrete Finisher
  • Supervision
  • Office Personnel

• Length of Employment:

• Date and time of incident:

  Date

• Day of the week

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Date and time incident was reported:

  Date

• Type of Incident:

  Select Injury Injury - First Aid Injury - Report Only Equipment Accident Auto Accident Property Damage

  • Injury
  • Injury - First Aid
  • Injury - Report Only
  • Equipment Accident
  • Auto Accident
  • Property Damage

• To whom was the incident reported?

• Location of incident. (Specify site location)

• Weather Conditions:

  Select Sunny Cloudy Raining Snowing Foggy Clear Early Morning/Late Evening

  • Sunny
  • Cloudy
  • Raining
  • Snowing
  • Foggy
  • Clear
  • Early Morning/Late Evening

• Temperature:

SECTION 2 - DETAILS OF INJURY (IF APPLICABLE)

• Was anyone injured? (If no, select N/A and skip to section 3)

  Yes

  No

  N/A

• Employee

• Other

• Describe what happened:

• Photograph what injured individual

  Media

• If employee, who assigned the task to the employee?

• Type of work employee was doing at time of injury:

  Select Grading Excavation Paving (Asphalt or Concrete) Concrete (Structural) Concrete (Non-structural) Maintenance Bridge Work Box Structure Form and Pour Silo Work Materials Utility Installation (Water, Sanitary, Storm) Office Driving

  • Grading
  • Excavation
  • Paving (Asphalt or Concrete)
  • Concrete (Structural)
  • Concrete (Non-structural)
  • Maintenance
  • Bridge Work
  • Box Structure
  • Form and Pour
  • Silo Work
  • Materials
  • Utility Installation (Water, Sanitary, Storm)
  • Office
  • Driving

• What was the employee doing when injured? (Be specific)

• What was the employee instructed to do?

• What is the normal procedure for completing the task?

• What tools/equipment was the employee using?

• What protective equipment was being used? If not why?

• Nature of Injury:

  Select Strain / Sprain Fracture Laceration / Cut Bruising Scratch / Abrasion Amputation Dislocation Internal Injuries Burn / Scald Foreign Body Chemical Reaction Allergic Reaction Concussion

  • Strain / Sprain
  • Fracture
  • Laceration / Cut
  • Bruising
  • Scratch / Abrasion
  • Amputation
  • Dislocation
  • Internal Injuries
  • Burn / Scald
  • Foreign Body
  • Chemical Reaction
  • Allergic Reaction
  • Concussion

• Other:

• Location of Injury:

  Select Head / Face Right Hand Right Eye Left Eye Internal Organs Right Shoulder Left Shoulder Right Arm Left Arm Right Hand Left Hand Finger(s) Trunk (other than back) Back Right Leg Right Knee Left Knee Right Foot Left Foot Left Leg Hip(s) Neck Groin

  • Head / Face
  • Right Hand
  • Right Eye
  • Left Eye
  • Internal Organs
  • Right Shoulder
  • Left Shoulder
  • Right Arm
  • Left Arm
  • Right Hand
  • Left Hand
  • Finger(s)
  • Trunk (other than back)
  • Back
  • Right Leg
  • Right Knee
  • Left Knee
  • Right Foot
  • Left Foot
  • Left Leg
  • Hip(s)
  • Neck
  • Groin

• What treatment did the employee receive:

  No Treatment

  First-Aid

  Sent to Medical Facility

  Sent to Hospital

• Name and address of medical treatment facility

SECTION 3 - DETAILS OF PHYSICAL DAMAGE, IF APPLICABLE

• Was there any physical damage to property, equipment or auto (if no, select N/A and proceed to section 4)

  Yes

  No

  N/A

• Describe what happened.

• Insert drawing of damage location?

  Yes

  No

  N/A

• Drawing

  Drawing

• Property Damage:

  None

  Minor

  Serious

  Major

• Photos of damage:

  Media

• Vehicle or Equipment #1

• Employee Name:

• Passengers?

  Yes

  No

  N/A

• Names:

• Make of Vehicle or Equipment:

• Vehicle ID:

• Vehicle or Equipment Damage:

  None

  Minor Damage

  Moderate Damage

  Severe Damage

• Photos of Damage:

  Media

• Vehicle or Equipment #2

• Employee Name or Other Drivers Name:

• Passengers?

  Yes

  No

  N/A

• Names:

• Make of Vehicle or Equipment:

• Vehicle or Equipment ID:

• Vehicle/Equipment Damage:

  None

  Minor Damage

  Moderate Damage

  Severe Damage

• Photos of Damage:

  Media

SECTION 4 - ROOT CAUSE ANALYSIS

• Why did it happen? (Root Cause Analysis) - What was the root cause of the incident i.e. actually caused the illness, injury or accident?)

• Was a JHA performed by the supervisor and documented?

  Yes

  No

  N/A

• Stretch and Flex performed today?

  Yes

  No

  N/A

• Who trained the employee on the hazards and protective measures for this task?

• What training was given to employee?

• What safety rules were in place to prevent this type of incident?

• Was the supervisor within sight of the incident?

  Yes

  No

  N/A

• When had the supervisor last checked on progress?

• Where was the supervisor at the time of the incident?

• Unsafe Acts

  Select Failure to Lockout/Tagout Using defective equipment Improper work technique Improper PPE, not used or used correctly Safety rule violation Operating without qualification or authorization Failure to warn or secure Operating equipment at an unsafe speed Bypass or removal of safety devices Taking an unsafe position or posture Improper Loading or Placement Improper lifting Use of tools for other than their intended purpose Servicing or adjusting machinery in motion Horseplay Drug or Alcohol Use Unsafe act(s) of others

  • Failure to Lockout/Tagout
  • Using defective equipment
  • Improper work technique
  • Improper PPE, not used or used correctly
  • Safety rule violation
  • Operating without qualification or authorization
  • Failure to warn or secure
  • Operating equipment at an unsafe speed
  • Bypass or removal of safety devices
  • Taking an unsafe position or posture
  • Improper Loading or Placement
  • Improper lifting
  • Use of tools for other than their intended purpose
  • Servicing or adjusting machinery in motion
  • Horseplay
  • Drug or Alcohol Use
  • Unsafe act(s) of others

• Unsafe Acts (Other):

• Unsafe Conditions

  Select Defective tools, equipment or supplies Inadequate supports or guards Congested Work Area Lack of adequate guards Lack of adequate warning system Fire or explosion hazards Poor housekeeping Poor workstation design or layout Hazardous atmospheric condition Inadequate ventilation Excessive noise Hazardous Substances Improper material storage Insufficient job knowledge Slippery Conditions Defective Tools/Equipment Insufficient lighting Inadequate Fall Protection Protruding object hazards

  • Defective tools, equipment or supplies
  • Inadequate supports or guards
  • Congested Work Area
  • Lack of adequate guards
  • Lack of adequate warning system
  • Fire or explosion hazards
  • Poor housekeeping
  • Poor workstation design or layout
  • Hazardous atmospheric condition
  • Inadequate ventilation
  • Excessive noise
  • Hazardous Substances
  • Improper material storage
  • Insufficient job knowledge
  • Slippery Conditions
  • Defective Tools/Equipment
  • Insufficient lighting
  • Inadequate Fall Protection
  • Protruding object hazards

• Unsafe Conditions (Other):

• Management System Deficiencies

  Select Lack of Written Procedures or Safety Rules Safety Rules Not Enforced Hazards Not Identified PPE Unavailable Insufficient Worker Training Insufficient Supervisor Training Improper Maintenance Inadequate Supervision Insufficient Job Planning Failure To Pre-Task Inadequate Workplace Inspections Inadequate Equipment Unsafe Design or Construction Unrealistic Scheduling

  • Lack of Written Procedures or Safety Rules
  • Safety Rules Not Enforced
  • Hazards Not Identified
  • PPE Unavailable
  • Insufficient Worker Training
  • Insufficient Supervisor Training
  • Improper Maintenance
  • Inadequate Supervision
  • Insufficient Job Planning
  • Failure To Pre-Task
  • Inadequate Workplace Inspections
  • Inadequate Equipment
  • Unsafe Design or Construction
  • Unrealistic Scheduling

• Management System Deficiencies (Other):

• List immediate actions taken:

• What should be done to prevent recurrence? (Be specific as to what would prevent the injury, incident or damage from occurring again)

• Was the 3-Hour Safety Training completed?

  Yes

  No

  N/A

SECTION 5 - STATEMENTS

• Were there any witnesses to the incident?

  Yes

  No

  N/A

• Witness Statement

• Signature of Witness

  Sign

• Witness Statement - (if photographed statement)

  Media

• Employee Statement

• Signature of Employee

  Sign

• Employee Statement - (if photographed statement)

  Media

SECTION 6 - REPORTED BY / DATE

• Additional Comments:

• Signature

  Sign