JMCC Accident / Incident Investigation Form R8

• Job #

• Job Name

• ViewPoint Reference #

• Audit Title

• Client / Site

• Site Supervision:

• Conducted on

  Date

• Prepared by

• Weather Condition:

• Overall visibility

• Location
  Address

Accident/Incident Details

• Employee / Injured Party Name:

• Is the injured party an employee of JMCC? If the answer is no, list Sub-Contractor or Affiliation to project.

  Yes

  No

  N/A

• Trade:

  Select Labor Carpenter Iron Worker Plumber Electrician Painter / Taper Visitor Project Management Mill Worker Safety Manager Company Executive Finisher Teamster / Driver Operator Project Owner / Rep Sheet Metal Worker Pipe Fitter Brick Layer

  • Labor
  • Carpenter
  • Iron Worker
  • Plumber
  • Electrician
  • Painter / Taper
  • Visitor
  • Project Management
  • Mill Worker
  • Safety Manager
  • Company Executive
  • Finisher
  • Teamster / Driver
  • Operator
  • Project Owner / Rep
  • Sheet Metal Worker
  • Pipe Fitter
  • Brick Layer

• Indicate Employees Union Local affiliation:

• Date and time of injury;

  Date

• Describe nature of injury:

  Select Laceration Contusion Strain Sprain Puncture Struck By

  • Laceration
  • Contusion
  • Strain
  • Sprain
  • Puncture
  • Struck By

• Describe what employee was doing at the time of injury:

• Was employee working on assigned task? Give details.

  Yes

  No

  N/A

• Who assigned task to employee?

• Was a Pre-Task / Tool box Talk training completed before work began? (Attach Copies)

  Yes

  No

  N/A

• Photograph copies of training documents (attach here)

  Media

• What were fellow co-workers / trades assignment at the time of injury?

• Were co-workers or other tradesmen present at time of injury? (List individually)

• Were there any witnesses?

  Yes

  No

  N/A

• Witness Statement:

• Witness

• Witness Signature:

  Sign

• Employee Statement:

• Employee signature:

  Sign

• Location of accident (please be specific)

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

• photo of work area

  Media

• photo of task and body position

  Media

• Photo of injury (if possible)

  Media

• Were tools being carried or used at time of incident

  Yes

  No

  N/A

• Describe tools being used or carried at time of incident:

• Did the use of tools, equipment or material play a role in this incident?

  Yes

  No

  N/A

• Describe how tools, equipment or material affected this incident:

• Were photo's taken at time of incident by anyone else beside person completing this form?

  Yes

  No

  N/A

• Who took other photo's and what is their affiliation to the project? (Please List with contact info)

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

Injury Details if Applicable

• Was first aid provided at time of injury?

  Yes

  No

  N/A

• Did employee decline medical treatment at time of injury?

  Yes

  No

  N/A

• Did injured employee go to clinic to receive medical attention for injury?

  Yes

  No

  N/A

• Name and Location of assigned facility.

• Were any chemicals involved in incident?

  Yes

  No

  N/A

• Describe chemicals and photo label on can and photo of SDS (aka) MSDS for chemical.

• Add media

  Media

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

• Was employee released to full / regular duty?

  Yes

  No

  N/A

• Was post accident drug testing performed?

  Yes

  No

  N/A

• Was the employee released to work with restrictions?

  Yes

  No

  N/A

• Describe in detail restrictions:

• Is there a follow up appointment, if so when? (Select date & time)

  Date

• Is there a light duty position available based on restrictions?

  Yes

  No

  N/A

Action: Short Term

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

Action: Long Term

• What are the long term action or actions needed to correct and avoid this issue? (describe)

Additional Information

• Drawings applicable to Incident

  Drawing

• Are there any attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.

  Yes

  No

  N/A

• Attachment Details here:

  Media

Person Completing Form (please sign below)

• Investigation by:

  Sign