JMCC Accident / Incident Investigation Form R9

• Date, Initials, Job #

• Job Name

• Audit Title

• ViewPoint Reference #

• Site Supervision:

• Conducted on

  Date

• Prepared by

• Weather Condition:

• Overall visibility

• Location
  Address

1. Accident/Incident Details

• 1a. Employee / Injured Party Name:

• 1b. Was injury or incident reported immediately? (To whom)

  Yes

  No

  N/A

• 1c. Date & Time reported:

  Date

• 1d. Is the injured party an employee of JMCC? If the answer is no, list Sub-Contractor or Affiliation to project.

  Yes

  No

  N/A

• 1e. 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 Tech Engineer

  • 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
  • Tech Engineer

• 1f. Indicate Employees Union Local affiliation:

• 1g. Location of accident (please be specific)

• 1h. Date and time of injury;

  Date

• 1i. Describe nature of injury:

  Select Laceration Contusion Strain Sprain Puncture Struck By Fracture Illness

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

• 1j. Describe what employee was doing at the time of injury:

• 1k. Was employee working on assigned task? Give details.

  Yes

  No

  N/A

• 1l. Who assigned task to employee?

• 1m. Was a Pre-Task / Tool box Talk training completed before work began? (Attach Copies)

  Yes

  No

  N/A

• 1n. Photograph copies of training documents (attach here)

  Media

2. Statements: Witness, Employee, & Foreman

• 2a. What were fellow co-workers / trades assignment at the time of injury?

• 2b. Were co-workers or other tradesmen present at time of injury? (List individually)

• 2c. Were there any witnesses?

  Yes

  No

  N/A

• 2d. Witness Statement:

• 2e. Witness

• 2f. Witness Signature:

  Sign

• 2g. Foreman Statement:

• 2h. Foreman Signature:

  Sign

• 2i. Employee Statement:

• 2j. Employee signature:

  Sign

• 2k. Describe who, what, when,where, why and how injury occurred:

• 2l. photo of work area

  Media

• 2m. photo of task and body position

  Media

• 2n. Photo of injury (if possible)

  Media

3. Contributing Causes:

• 3a. Were tools being carried or used at time of incident

  Yes

  No

  N/A

• 3b. Describe tools being used or carried at time of incident:

• 3c. Did the use of tools, equipment or material play a role in this incident?

  Yes

  No

  N/A

• 3e. Describe how tools, equipment or material affected this incident:

• 3f. Were photo's taken at time of incident by anyone else beside person completing this form?

  Yes

  No

  N/A

• 3g. Who took other photo's and what is their affiliation to the project? (Please List with contact info)

• 3h. Contributing Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilize safety equipment)

• 3i. Were any chemicals involved in incident?

  Yes

  No

  N/A

• 3j. Describe chemical label on can and SDS (aka) MSDS for chemical.

• 3k. Photographs of label if possible.

  Media

4. Injury Details

• 4a. Was first aid provided at time of injury?

  Yes

  No

  N/A

• 4b. Did employee decline medical treatment at time of injury?

  Yes

  No

  N/A

• 4c. Was post accident drug testing performed?

  Yes

  No

  N/A

• 4d. Did injured employee go to clinic to receive medical attention for injury?

  Yes

  No

  N/A

• 4f. Name and Location of assigned facility.

• 4g. Was employee released to full / regular duty?

  Yes

  No

  N/A

• 4h. Was the employee released to work with restrictions?

  Yes

  No

  N/A

• 4i. Describe in detail restrictions:

• 4j. Is there a follow up appointment, if so when? (Select date & time)

  Date

• 4k. Is there a light duty position available based on restrictions?

  Yes

  No

  N/A

5. Corrective Action: Short Term

• 5a. What was the immediate action taken to correct the issue (how was this done):

6. Corrective Action: Long Term

• 6a. What are the long term corrective action or actions needed to correct and avoid this issue? (describe)

7. Additional Information

• 7a. Drawings applicable to Incident

  Drawing

• 7b. Are there any attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.

  Yes

  No

  N/A

• 7c. Attachment Details here:

  Media

• 7d. Additional Information notes:

8. Person Completing Form (please sign below)

• 8a. Investigation by:

  Sign