Accident/Incident Details

  • Employee Name

  • Date and time of injury;

  • Was employee working overtime? Give details.

  • Department:

  • 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:

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

  • photo of work area

  • photo of task and body position

  • 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?

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

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

Person Completing Form (please sign below)

  • Investigation by:

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