This section to be filled out by employee

  • Adreess of employee

  • Employees phone number

  • employees date of birth

  • Date and time of injury

  • Time your shift started on day of injury

  • Department

  • Ware did the accident happen- be specific

  • Give a description of the incident

  • Type of injury/illness

  • explain

  • What part of body is hurt- add photo of injury if appropriate

  • Job title

  • How long have you been on this Job? not with the company but this job

  • Supervisor(s) on duty

  • Do you work for another employer?

  • Who?

  • Employee signature

Witness Statement 1

  • What did you see happen

  • Add signature

Witness Statement 2

  • What did you see happen?

  • Add signature

To be filled out by supervisor

  • Was a safety stand down conducted?

  • Was the Triage Nurse called

  • Why not?

  • Was injury reported the day it happened?

  • If no Why

  • Did employee receive medical attention?

  • what kind of care?

  • who?

  • Was injured admitted for overnight hospital stay?

  • Task being preformed at time of injury

  • Materials/equipment used

  • What was employee doing right before injury

Machinery/Equipment involved - to be filled out by Supervisor

  • Was equipment or machinery involved?

  • What Equipment

  • Was there any mechanical failure?

  • Explain

Contributing Factors - To be filled out by supervisor

  • Contributing Factors: Description why this factor contributed or caused the incident (Typically there is more than a single casual factor):

  • Contributing Factors Photo

  • Contributing Factors Photo

  • Was there an Unsafe Condition?

  • What unsafe Condition

  • Was there an Unsafe Act

Training

  • Did employee receive specific training or instructions relating to safety and health on job being performed?

  • Type

  • Instructed by

  • Date of last refresher training

Personal Protective Equipment

  • Did employee use appropriate PPE for the job/task performed?

  • Did equipment fail? If so, describe

  • Describe failure of equipment

Root Cause Analysis

  • How did the injury occur?

  • Why did that occur? (answer from last question)

  • Why did that occur? (answer from last question)

  • Why did that occur? (answer from last question)

  • Why did that occur? (answer from last question)

  • Why did that occur? (answer from last question)

  • What is the Root Cause?

Corrective Actions - To be filled out by EHS

  • Were any corrective or preventative actions taken due to the incident?

  • What actions

  • Is retraining required?

Management/Administrative actions

  • Is any further action required? If yes, state action to be taken

  • What action ?

  • Are all corrective actions completed?

  • What corrective action is not completed?

  • when will it be completed?

  • Is unsafe condition eliminated or mitigated to prevent future unsafe acts or conditions from occurring?

  • Why Not

  • Is Plant management satisfied with plan of action and investigation

Signatures

  • Supervisor

  • Department Head

  • Plant Mgr.

  • Safety Mgr.

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