Injury, Accident, Incident Report

• Accident Injury Report

  Select Injury - First Aid (treated on site) Injury - Taken to clinic or hospital off site Incident - no damage Incident - damage noted

  • Injury - First Aid (treated on site)
  • Injury - Taken to clinic or hospital off site
  • Incident - no damage
  • Incident - damage noted

• Document No.

• Job Name

• Conducted on

  Date

• Prepared by

• Location
  Address

SECTION I : The Basics

• Name of person involved

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• Who was the accident first reported to?

• Location of incident. (Specify site location)

• Was there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A

SECTION 2: DETAILS OF INJURY / INCIDENT, IF APPLICABLE

• What is the cause of injury?

  Select Struck by Caught by Pinched by Crushed by Impact from fall Cut by

  • Struck by
  • Caught by
  • Pinched by
  • Crushed by
  • Impact from fall
  • Cut by

• Describe injury.

• Detail any first-aid or medical treatment administered. (Provide names)

Section 3: DETAILS OF DAMAGE, IF APPLICABLE

• Property Damage:

  None

  Minor

  Serious

  Major

• Photo of damage.

  Media

• Vehicle ID:

• Detailed description of incident. (Include environmental conditions at time of incident)

• Immediate (Direct Causes):

• Direct cause photo:

  Media

• Direct cause photo:

  Media

Section 4: ANALYSIS

• Severity of injury

  First Aid

  Reportable (work comp)

  OSHA Recordable

• Nature of injury

  Select SLIP - TRIP - FALL Pinched by Crushed by Struck by Ergonomic (repetitive, or MSD) Cut by Burned by (thermal)

  • SLIP - TRIP - FALL
  • Pinched by
  • Crushed by
  • Struck by
  • Ergonomic (repetitive, or MSD)
  • Cut by
  • Burned by (thermal)

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• What could be done to prevent this from occurring again?

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Select date

  Date

• Signature

  Sign

Safety Department Investigation Root Cause 5 why

• Why did employee incur incident or injury?

• Repeat answer for previous why, then ask why again

• Repeat answer for previous why, then ask why again

• Repeat answer for previous why, then ask why again

• Repeat answer for previous why, then ask why again