INJURY & ILLNESS REPORT

• INCIDENT INVESTIGATION

• Jobsite:

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• Project Manager

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• General Contractor

  Select

• General Superintendent:

  Select

• Project Superintendent:

  Select

• Weather (Take Screenshot from Heat Index App):

  Media

• Contacted Tom Isola @ 407.607.5111

  Yes

  No

1. REPORT COMPLETED BY

• Completed By:

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• Title:

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• Date:

  Date

2. INFORMATION ABOUT THE EMPLOYEE (#1 NOT REQUIRED)

• Employee Number

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• Full Name:

• Street:

• Apt#:

• City:

• State:

• Phone#:

• Primary Language Spoken:

  Select

3. CASE INFORMATION: (#1, 2, 9, 10 NOT REQUIRED)

• 1) Case Number from the Log:

• 2) Job Title:

  Select

• 3) Date of Injury or onset of Illness:

  Date

• 4) Where the Event Occurred:

• 5) Describe Injury or Illness; Parts of the Body Affected, and Objects/Substance that Directly Injured or Made the Person Ill

• 9) Date of Birth:

  Date

• 10) Date of Hire:

  Date

4. INCIDENT INFORMATION:

• 12) Was Employee Treated in an Emergency Room:

  Yes

  No

• Name of Hospital

• Street:

• 13) Was Employee Hospitalized Overnight as an in-patient:

  Yes

  No

• 14) Time Employee Began Work: (Mobiclocks)

  Date

• 15) Time of Event:

  Date

• Re fields 16 to 20: Please do not include any personally identifiable information (PII) pertaining to worker(s) involved in the incident (e.g., no names, phone numbers, or Social Security numbers).

• 16) What Was the Employee Doing Just Before the Incident Occurred:

• Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: “climbing a ladder while carrying framing materials”; “spraying form oil from pump can”; “moving material with crane”

• 17) What Happened? Tell us How the Injury Occurred:

• Examples: "When ladder slipped on concrete slab, worker fell 12 feet”; “Worker was sprayed with form oil in face while spraying forms”; “Finger caught between skip pan and dumpster.”

• 18) What was the Injury or Illness:

• Examples: “fractured wrist”; “chemical burn, eyes”; “bruised finger.”

• 19) What object or substance directly harmed the Employee:

• Examples: “concrete slab”; “form oil”; “skip pan” If this question does not apply to the incident, leave it blank.

• 20) If the Employee Died, When did Death Occur:

  Date

• Medical Attention Required:

  Yes

  No

• Initial Treatment

  Select

• If Treatment was Given Away From the Worksite, Where was it Given:

  Select

• Drug Screen Conducted:

  Yes

  No

• THIS IS REQUIRED. CALL TOM ISOLA WITH ANY QUESTIONS

5. INJURY DETAILS

• Date & Time Incident Reported:

  Date

• Person Reported to:

• Did the Injury Occur in Course of Employment:

  Yes

  No

• What Part of Employee’s Workday Did the Incident Occur:

  Select

• Was the Employee Working:

  Select

• Rate the Pain from a Scale of 1-10:

• Why Did it Happen - Workplace Conditions:

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• Why Did it Happen - Unsafe Acts of People:

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• Work Status:

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• Pictures of Accident:

  Media

6. BODY INJURIES

BODY AREA #1

• Area of Body:

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• Side of Body:

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BODY AREA #2

• Area of Body:

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• Side of Body:

  Select

BODY AREA #3

• Area of Body:

  Select

• Side of Body:

  Select

7. WITNESSES

• Name & Phone #

• Name & Phone #

• Name & Phone #

8. CORRECTIVE ACTIONS

• HOW CAN FUTURE INCIDENTS BE PREVENTED?

  Select

9. CONTRIBUTING FACTORS

• A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident occurring and deeply understanding the underlying cause. One tactic to determine this is through asking "Why?" five times, to uncover the core of a problem.

• Experience in Construction Prior to Working with Universal:

  Select

• Was the worker following the guidelines to the specific job task?

  Yes

  No

• Was a Pre-Task completed for this work procedure?

  Yes

  No

• Did the foreman and crew discuss a detailed work plan?

  Yes

  No

• Did the work plan address the identified hazard(s)?

  Yes

  No

• Were the tools and equipment right for the job?

  Yes

  No

• Was the employee capable, trained, and qualified to do this work?

  Yes

  No

• Was there enough time to do the task safely?

  Yes

  No

• Does the employee normally do this task?

  Yes

  No

• Was human factor such as the person’s size or strength a factor?

  Yes

  No

• Did the sun, heat, cold, wind, dust, glare, fatigue contribute to the incident?

  Yes

  No

• Was the injury a result of the Pre-Task not being followed?

  Yes

  No

• Was the worker a new hire (GREEN TAPE) or a transfer (RED TAPE)?

  GREEN

  RED

  N/A

• Was a Safety Rule of Specific Instruction Violated?

  Yes

  No

EMAIL TO THE FOLLOWING:

• Project Manager, General Sup't, Project Sup't and copy Todd Volheim, Bill Nagele, Heman Higgins, Tom Isola