JE Richards Incident Investigation

• Investigation Title

• Project Number

  Yes

  No

  N/A

• Foreman

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Project Manager

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Conducted on

  Date

• Prepared by

• Location
  Address

Incident Information

• Date/Time of Occurrence

  Date

• Has Safety Administrator been notified of injury?

• Incident Type

  Select Injury Illness Fire Automobile Property Damage Near Miss Spill/Leak/Release Other

  • Injury
  • Illness
  • Fire
  • Automobile
  • Property Damage
  • Near Miss
  • Spill/Leak/Release
  • Other

• Name of Injured

• Employee Classification

• Injury Type

  Select Report Only First Aid OSHA Recordable OSHA DART OSHA Lost Time Fatality

  • Report Only
  • First Aid
  • OSHA Recordable
  • OSHA DART
  • OSHA Lost Time
  • Fatality

• Specific Location of Incident

• Treatment Location

Witness Information

• Has the Injured Person's statement been reviewed and turned into the office?

  Yes

  No

  N/A

• Has the Foreman's incident report and statement been reviewed and turned into the office?

  Yes

  No

  N/A

• Witness (please attach or email statements from all involved)

• Witness

  Pass

  Fail

  N/A

• Witness

  Pass

  Fail

  N/A

• Witness

  Pass

  Fail

  N/A

Incident Details

• Briefly describe the incident (be detailed and descriptive)

• Photos

  Media

Task Description

• What was the task?

• Who was assigned to the task, and who was in charge?

• How many people were in the crew?

• What was being used to complete the task?

• What hazards existed or were created as part of this task?

• Was a Pre-Task Plan conducted for this task?

  Yes

  No

  N/A

Conclusions

• Root Cause(s) (Mandatory)

• What could have prevented this incident?

• Recommendations

• What follow up actions have been conducted or are required?

Summary/Notes

• Has the General Contractor and/or Customer been notified of the incident?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Who was involved in the investigation? Please list all Parties.

  Select JE Richards Safety Professional Foreman Project Manager Other JE Richards Employee General Contractor Safety Professional Other General Contractor Representative OTHER (Describe Below)

  • JE Richards Safety Professional
  • Foreman
  • Project Manager
  • Other JE Richards Employee
  • General Contractor Safety Professional
  • Other General Contractor Representative
  • OTHER (Describe Below)

• Who else was involved in the investigation?

• Injury Follow up apt?

• Any special Restrictions or modified duty?

• Additional comments

• Investigator signature

  Sign

• Add signature

  Sign