Investigation

  • This form is to be completed by the Manager and employees involved in an incident. An incident is defined as any unplanned event that contributes to or could have contributed to a Near miss, injury or property damage. The form should be submitted to the EHS manager within 24 hrs from the day of the incident.

  • Identify parties involved with the incident.

Date, Time and Location of Incident

  • DATE & TIME OF INCIDENT

  • Department

  • SPECIFIC LOCATION OF INCIDENT

CONTACTS

  • Manager

  • Phone Number

  • Was there more than one employee involved?

  • List all Employees involved and their demographic information

  • Employee(s) involved
  • Employee's Name

  • Employee's Occupation

  • Employee's address, city, state, zip
  • Employee's Phone

  • Male/Female

  • Date of hire

  • Serious Incidents include: Head Injuries (loss of consciousness), Heart Attacks, Amputations, Fractures in two or more bones, Serious Burns (3rd degree), Hospitalizations,

    Significant Property Damage is considered when damages are anticipated to exceed $100,000.

Classification

  • Severity of Incident

  • Estimated days of restricted duty (if known)

  • Date of next medical appointment

  • Describe seriousness of incident. If the incident is an OSHA reportable case, the incident details must be called into the OSHA 800 line.

  • Date and Time OSHA notified

  • Date and Time Broker notified (for Significant Property Damage).

  • List medical treatment received and future medical care (if known)

  • Drug/Alcohol screen completed

Incident Description

  • Date and Time incident was reported

  • Reported to:

  • Type of Incident

  • Nature of Incident

  • Initial incident reported to Senior Management:

Employee(s) Statement

  • Were two or more employees involved?

  • Summarize or attach employee(s) statements

  • Employee statements
  • Type or hand write Employee's statement. Please describe what activities were performed when the incident occurred.

  • Employee's signature

  • Date and time of statement

  • Type or hand write Employee's statement. Please describe what activities were performed when the incident occurred.

Brief Description

  • Summary of Incident

SEQUENCE OF EVENTS

  • What was (were) employee(s) doing at the time of the incident?

  • SEQUENCE OF EVENTS

  • Add diagrams/drawings and measurements to support analysis

  • Supporting photographs

INDICATION OF INJURIES

  • WERE EMPLOYEE(s) INJURED?

  • SELECT BODY PART(s).

  • SIDE

  • DETAILS OF INJURY?

  • If Medical Treatment received, who provided the care?

  • Date/Time of medical treatment

  • PHOTOGRAPHS OF INJURY

INDICATION OF DAMAGE TO PROPERTY

  • WAS THERE ANY DAMAGE TO PROPERTY?

  • RECORD DETAILS AND EXTENT OF DAMAGE

  • PHOTOGRAPHS OF DAMAGE

  • List estimated costs of property damages.

WITNESSES

  • WERE THERE ANY WITNESSES?

  • Name of witness

  • Position

  • Did the witness directly observe the incident?

  • Summary of Witnesses Statement

OBSERVATIONS/CONTRIBUTING FACTORS

  • CONTRIBUTING FACTORS

  • Additional supporting factors

  • List tools, equipment, materials or chemicals used at the time of the incident.

RECOMMENDATIONS (include any corrective, preventive actions)

  • Corrective Action Categories

  • List each corrective action plan associated with each corrective action category.

  • Corrective Action Plans
  • Corrective Action

  • Person(s) assigned to CAP

  • Additional people/resources involved to complete CAP

  • Describe Corrective Action Plans (CAP)

  • Anticipated Date to complete

  • Estimated direct costs to complete

  • Add photo

REPORT COMPLETED BY

  • ANALYSIS COMPLETED BY:

  • DATE OF REPORT

  • OPERATIONS REVIEW

  • DATE OF REVIEW

  • CEO REVIEW

  • DATE OF CEO REVIEW

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