JMC Accident/Incident & Investigation Form 2012

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Accident/Incident Details

• Employee Name

• Date and time of injury;

  Date

• Was employee working overtime? Give details.

  Yes

  No

  N/A

• Department:

  Select Labor Galvanizing welder carpenter conduit coupling shipping outside shipping CW mill mill wright testing finishing MZR Guard storeroom

  • Labor
  • Galvanizing
  • welder
  • carpenter
  • conduit
  • coupling
  • shipping
  • outside shipping
  • CW mill
  • mill wright
  • testing
  • finishing
  • MZR
  • Guard
  • storeroom

• Location of accident (please be specific to department in plant)

• Nature of Incident or Injury

• Was a JSA, Risk Assessment, SCS, or training completed before work began:

  Yes

  No

  N/A

• Describe who, what, when,where, why and how injury occurred:

• photo of work area

  Media

• photo of task and body position

  Media

• on scale of 0 to 10 (10 = broken bone through skin) how bad did injury hurt when occurred

• Root causs of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)

• Contributing Causes or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilise safety equipment)

• What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)

• Witnesses

• Witnesses

Injury Details if Applicable

• Part of Body injured:

• Do we have Light duty for him based on restrictions?

  Yes

  No

  N/A

Corrective Actions

Action: Short Term

• What was the immediate action taken to correct the issue (how was this done):

Action: Long Term

• What is the long term action needed to correct the issue:

Additional Information

• Drawings applicable to Incident

  Drawing

• Please provide all attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.

  Yes

  No

  N/A

Person Completing Form (please sign below)

• Investigation by:

  Sign