MEADOW GOLD DAIRY - EMPLOYEE INJURY & INVESTIGATION REPORT

• Injured Employee Name:

  Select

• Date of injury

  Date

This section to be filled out by employee

• Adreess of employee

• Employees phone number

• employees date of birth

• Date and time of injury

  Date

• Time your shift started on day of injury

  Date

• Department

  Select

• Ware did the accident happen- be specific

• Give a description of the incident

• Type of injury/illness

  Select

• explain

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

  Select

• Job title

  Select

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

  Select

• Supervisor(s) on duty

  Select

• Do you work for another employer?

  Yes

  No

• Who?

• Employee signature

  Sign

Witness Statement 1

• What did you see happen

• Add signature

  Sign

Witness Statement 2

• What did you see happen?

• Add signature

  Sign

To be filled out by supervisor

• Was a safety stand down conducted?<br>

  Yes

  No

• Was the Triage Nurse called

  Yes

  No

• Why not?

• Was injury reported the day it happened?

  Yes

  No

• If no Why

• Did employee receive medical attention?

  Yes

  No

• what kind of care?

  Self treatment

  First-aid by coworker

  emergency room

  Work Med

• who?

  Select

• Was injured admitted for overnight hospital stay?

  Yes

  No

• 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? <br>

  Yes

  No

• What Equipment

• Was there any mechanical failure?

  Yes

  No

• 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

  Media

• Contributing Factors Photo

  Media

• Was there an Unsafe Condition?

  Yes

  No

• What unsafe Condition

• Yes

  No

  N/A

• Was there an Unsafe Act

  Yes

  No

• Select

Training

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

  Yes

  No

• Type

• Instructed by

• Date of last refresher training

  Date

Personal Protective Equipment

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

  Yes

  No

• Did equipment fail? If so, describe

  Yes

  No

• 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?

  Yes

  No

• What actions

• Is retraining required?<br>

  Yes

  No

Management/Administrative actions

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

  Yes

  No

• What action ?

• Are all corrective actions completed?

  Yes

  No

• What corrective action is not completed?

• when will it be completed?

  Date

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

  Yes

  No

• Why Not

• Is Plant management satisfied with plan of action and investigation

  Yes

  No

• Supervisor

  Sign

• Department Head

  Sign

• Plant Mgr.

  Sign

• Safety Mgr.

  Sign