Nasatka Accident/Incident & Investigation Form (Rev0)

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Part A. Accident/Incident portion.

• Select date

  Date

• Name Branch that employee was working for:

  Florida

  Georgia

  North Carolina

  Texas

• Employee Name (First, MI, Last): (Look at ID)

  Yes

  No

  N/A

• SSN #

  Yes

  No

  N/A

• Date of Birth:

  Yes

  No

  N/A

• Did employee die?

  No

  Yes

• Gender:

  Male

  Female

• Date of Injury/Icident:

  Yes

  No

  N/A

• Time of Injury/Incident:

  Yes

  No

  N/A

• Return to work date/or expected date:

  Yes

  No

  N/A

• Will the employee have any restrictions?

  No

  Yes

• If so, what are they?

  Yes

  No

  N/A

• Do we have Light Duty for him based on restrictions?

  No

  Yes

• Date and Time the employer was notified:

  Yes

  No

  N/A

• Employee's Home Address and Phone Number:

  Yes

  No

  N/A

• Does Employee Speak English?

  No

  Yes

• What Language?

  Spanish

  Chinese

  French

  Italian

• Marital Status:

  Select Single Married Widowed Divorced Separated

  • Single
  • Married
  • Widowed
  • Divorced
  • Separated

• Number of Dependents:

  Select 1 2 3 4 5 6 7 8 9

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9

• Number of Dependents under 18:

  Select 1 2 3 4 5 6 7

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7

• Spouse's Name:

  Yes

  No

  N/A

• Hire Date:

  Yes

  No

  N/A

• Avg. Hrs Worked Per Week:

  Yes

  No

  N/A

• Avg. Weekly Wage:

  Yes

  No

  N/A

• Job Title:

  Insulator

  Fireproofer

  Waterproofer

• Did He Receive Full Pay For Date Of Injury?

  No

  Yes

• Superintendent Name and Phone Number:

  Yes

  No

  N/A

• Project Name, Number and Address Where Accident Occurred:

  Yes

  No

  N/A

• Witnesses?

  Yes

  No

  N/A

• Witnesses?

  Yes

  No

  N/A

• If the answer was yes, please provide Full Name, Phone Number and Employer:

  Yes

  No

  N/A

• If the answer was yes, please provide Full Name, Phone Number and Employer:

  Yes

  No

  N/A

• Where was the Medical Treatment first provided?

  Select Minor Onsite Physician/Clinic ER Treated/Released Hospitalized > 24 hrs Hospitalized < 24hrs No Medical Treatment

  • Minor Onsite
  • Physician/Clinic
  • ER Treated/Released
  • Hospitalized > 24 hrs
  • Hospitalized < 24hrs
  • No Medical Treatment

• What type of provider performed treatment?

  Clinic

  Hospital

  On-Site First Aid

• Providers Name:

  Concentra

  Florida Hospital Centra Care

  Other

• If you choose other please specify.

  Yes

  No

  N/A

• Provider Phone Number, Address and Name of the Doctor.

  Yes

  No

  N/A

• Anyone else injured:

  No

  Yes

• Name of the Superintendent and/or other office personnel who went with the injured to the clinic/hospital. This is mandatory and must stay there the entire time.

  Yes

  No

  N/A

• Nature of Injury?

  Yes

  No

  N/A

• Part of Body injured:

  Yes

  No

  N/A

• Was the employee doing his regular job?

  No

  Yes

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

  Yes

  No

  N/A

• Location of accident (please be specific)?

  Yes

  No

  N/A

Person Completing Part A ( please sing below)

• Add signature

  Sign

Part B. Investigation portion.

• Employee Name (First, MI, Last):

  Yes

  No

  N/A

• Contract Relationship (Company Name):

  Yes

  No

  N/A

• Date of Hire:

  Yes

  No

  N/A

• Was the person injured a new hire?

  Les than 90 days

  More than 90 days

• Which one applies to the accident / incident:

  Behavior

  Condition

• Total Yrs. of experience:

  Yes

  No

  N/A

• Incident Type:

  Property Damage

  Vehicle

  Near Miss

  Other

• Please explain further:

  Yes

  No

  N/A

• Severity:

  Select First Aid Recordable Lost Time Restricted Duty Fatality

  • First Aid
  • Recordable
  • Lost Time
  • Restricted Duty
  • Fatality

• Was a Pre-Job Safety Briefing Held before work began?

  Yes

  No

  N/A

• Was employee present?

  Yes

  No

  N/A

• Describe the work Activity in Progress at the time of the incident. (What was the Employee doing? How did the Incident occur?)

  Yes

  No

  N/A

• Describe the Incident. (Where was the employee? What was the employee doing? How did the Incident occur?)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)

  Yes

  No

  N/A

• What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)

  Yes

  No

  N/A

Corrective Actions

Action:

• What was the immediate action taken to correct the issue (how was this done)?

  Yes

  No

  N/A

• Who was the responsible party for correcting the issue?

  Yes

  No

  N/A

• Select date

  Date

Action:

• What is the long term action needed to correct the issue?

  Yes

  No

  N/A

• Who was the responsible party for correcting the issue?

  Yes

  No

  N/A

• Select date

  Date

• Lessons Learned:

  Yes

  No

  N/A

• Please provide all attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.

  Yes

  No

  N/A

Statement of Employee involved in the accident/incident

• Please provide date of incident,time, phone number and description of the incident according to the employee in his words:

  Yes

  No

  N/A

• Add signature

  Sign

Statement of the Witness (1)

• Name of witness, Company that he / she works for, Phone Number, Date and Time of the accident/incident according to the witness.

  Yes

  No

  N/A

• Statement in his words:

  Yes

  No

  N/A

• Add signature

  Sign

Statement of the Witness (2)

• Name of witness, Company that he / she works for, Phone Number, Date and Time of the accident/incident according to the witness.

  Yes

  No

  N/A

• Statement in his words:

  Yes

  No

  N/A

• Add signature

  Sign