Lytle Accident Investigation Report

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Document No.

Employee Information:

• Name of Injured:

• Social Security #:

• Date of Birth:

  Date

• Phone #:

• Address of Injured Employee:

• Sex:

  Male

  Female

• Date Hired:

  Date

• Employment Status:

  Full Time

  Part Time

  Other

• If other, explain:

• Job Classification:

  Supervisor

  Journeyman

  Apprentice

  Other

• Accident Date and Time:

  Date

Job Information:

• Job Name:

• Superintendent:

• Injurer's Immediate Supervisor:

• Accident Investigated by Whom:

• Person Reported To:

• Date Reported:

  Date

• Time Employee Started Work:

  Date

• Witness(es) To Accident:

Injury Information:

• Injury Source:

  Select Foreign Body Grinder Wheel Saw Blade Welding Arc Hand Tool Chemical Vehicle Other

  • Foreign Body
  • Grinder Wheel
  • Saw Blade
  • Welding Arc
  • Hand Tool
  • Chemical
  • Vehicle
  • Other

• If other, explain:

• Personal Factor:

  Select Attitude Attentiveness Lack of Skill or Knowledge Not Using Protective Equipment Physical Defect or Condition Job Site Deficiency Other

  • Attitude
  • Attentiveness
  • Lack of Skill or Knowledge
  • Not Using Protective Equipment
  • Physical Defect or Condition
  • Job Site Deficiency
  • Other

• If other, explain:

• Source of Accident:

  Select Powered Hand Tool Non-Powered Hand Tool Material Ladder Scaffold Chemical Concrete Stairs Steps Platform Floor Other

  • Powered Hand Tool
  • Non-Powered Hand Tool
  • Material
  • Ladder
  • Scaffold
  • Chemical
  • Concrete
  • Stairs
  • Steps
  • Platform
  • Floor
  • Other

• If other, explain:

Treatment Information:

• Treatment Given, if any:

• Location of Treatment Given:

  Select Job Site Emergency Room Doctors Office N/A Other

  • Job Site
  • Emergency Room
  • Doctors Office
  • N/A
  • Other

• If other, explain:

• Did Injured Leave Work:

  Yes

  No

• If yes, what time:

  Date

• Did Injured Return to Work:

  Yes

  No

  N/A

• If yes, what time:

  Date

• Lost Time/Days:

Injury Description:

• Body Part Injured:

  Select Ankle Arm Back Ear Eye Face Finger Foot Hand Forehead Head Hip Knee Leg Mouth Nose Ribs Shoulder Teeth Toe Thumb Wrist Other

  • Ankle
  • Arm
  • Back
  • Ear
  • Eye
  • Face
  • Finger
  • Foot
  • Hand
  • Forehead
  • Head
  • Hip
  • Knee
  • Leg
  • Mouth
  • Nose
  • Ribs
  • Shoulder
  • Teeth
  • Toe
  • Thumb
  • Wrist
  • Other

• Indicate Left or Right:

• Injury Photos:

  Media

• Type of Injury:

  Select Abrasion Burn Bruise/Contusion Cut/Laceration Dislocation Fracture Foreign Body Irritation Poisoning Sprain/Strain Other

  • Abrasion
  • Burn
  • Bruise/Contusion
  • Cut/Laceration
  • Dislocation
  • Fracture
  • Foreign Body
  • Irritation
  • Poisoning
  • Sprain/Strain
  • Other

• If other, explain:

• Type of Accident:

  Select Struck Against Struck By Caught In Fall Slip Sprain Strain Inhalation Arc Exposure Vehicle Other

  • Struck Against
  • Struck By
  • Caught In
  • Fall
  • Slip
  • Sprain
  • Strain
  • Inhalation
  • Arc Exposure
  • Vehicle
  • Other

• If other, explain:

• Injurers Activity at Time of Accident:

  Select Carrying Climbing Descending Driving Handling Material Horseplay Lifting Operating Machinery Pulling Pushing Using Hand Tools Walking Welding Other

  • Carrying
  • Climbing
  • Descending
  • Driving
  • Handling Material
  • Horseplay
  • Lifting
  • Operating Machinery
  • Pulling
  • Pushing
  • Using Hand Tools
  • Walking
  • Welding
  • Other

• If other, explain:

• PPE Used:

  Select Hard Hat Safety Glasses Steel Toe Shoes High Visibility Clothing Ear Plugs Other

  • Hard Hat
  • Safety Glasses
  • Steel Toe Shoes
  • High Visibility Clothing
  • Ear Plugs
  • Other

• Responsibility of Accident:

  Select Injured Employee Bad Practice Inherent Hazard of the Job Superintendent/Management Other

  • Injured Employee
  • Bad Practice
  • Inherent Hazard of the Job
  • Superintendent/Management
  • Other

• Unsafe Practice or Act:

  Select Failure To Use Protective Equipment Use Of Defective Tools or Equipment Using Hands Instead of Tools Operating Without Authority Failure to Secure Making Safety Devices Inoperative Working On Moving Equipment Taking Unsafe Positions Operating At Unsafe Speeds Unsafe Loading/Placing Horseplay Placing Tools/Material Too Close To Edge Placing Hands In Unsafe Position Improper Gripping Improper Lifting Failure to Observe Surroundings Failure To Secure Ladder Insecure Hitch Failure To Warn or Signal Unnecessary Climbing or Jumping Riding Equipment Other

  • Failure To Use Protective Equipment
  • Use Of Defective Tools or Equipment
  • Using Hands Instead of Tools
  • Operating Without Authority
  • Failure to Secure
  • Making Safety Devices Inoperative
  • Working On Moving Equipment
  • Taking Unsafe Positions
  • Operating At Unsafe Speeds
  • Unsafe Loading/Placing
  • Horseplay
  • Placing Tools/Material Too Close To Edge
  • Placing Hands In Unsafe Position
  • Improper Gripping
  • Improper Lifting
  • Failure to Observe Surroundings
  • Failure To Secure Ladder
  • Insecure Hitch
  • Failure To Warn or Signal
  • Unnecessary Climbing or Jumping
  • Riding Equipment
  • Other

• If other, explain:

• Unsafe Condition:

  Select Improper Arrangement Improper Procedure, Etc. Improper Dress Improperly Guarded Unguarded Defective Tools Improperly Maintained Poor Housekeeping Design or Construction Safety Device Missing Protective Equipment Not Provided Physical Deficiency Method or Process Improper Instructions Supervisory Failure Recognized Hazard Not Corrected Known Safety Rule Not Enforced Other

  • Improper Arrangement
  • Improper Procedure, Etc.
  • Improper Dress
  • Improperly Guarded
  • Unguarded
  • Defective Tools
  • Improperly Maintained
  • Poor Housekeeping
  • Design or Construction
  • Safety Device Missing
  • Protective Equipment Not Provided
  • Physical Deficiency
  • Method or Process
  • Improper Instructions
  • Supervisory Failure
  • Recognized Hazard Not Corrected
  • Known Safety Rule Not Enforced
  • Other

• If other, explain:

• Describe Accident:

• What Has Been Done to Prevent a Recurrence:

• Could This Accident Have Been Prevented:

  Yes

  No

• If yes, how:

Finalization:

• Report Prepared By:

• Signature:

  Sign

• Date:

  Date

• Title:

  Safety Director

  Foreman

  Project Manager

• Report Reviewed By:

• Signature:

  Sign

• Date:

  Date

• Title:

  Safety Director

  Foreman

  Project Manager