Northern Industrial Insulation Accident Investigation Report

• Conducted on

  Date

• Prepared by

Affected Employee Information

• Name of Employee

• Employee's Job Title

Incident Information

• Type of Incident

  Select Personal Injury Near Miss Property Damage Transportation Unsafe Condition

  • Personal Injury
  • Near Miss
  • Property Damage
  • Transportation
  • Unsafe Condition

• Date and Time of Incident

  Date

• Date and Time Incident was Reported

  Date

• Location of Incident

• Describe the Accident and How it Occurred

• Cause of Accident

• Cause of the Accident

• Was Personal Protective Equipment Required?

  Yes

  No

• Was Personal Protective Equipment Provided?

  Yes

  No

  N/A

• Was Personal Protective Equipment Being used?

  Yes

  No

  N/A

• If PPE was not being used please explain why.

• Witness(es) Name(s)

• Was Safety Training Provided to the Affected Employee?

  Yes

  No

  N/A

• Corrective Action to Prevent Reocurrence

• Pictures of the Scene / Incident

  Media

• Select No Physical Injury Amputation Asphyxiation Burn Concussion Contusion Crushing Dermatitis Dislocation Electric Shock Foreign Body Fracture Freezing Hearing Loss or Impairment Heat Illness Hernia Infection Inflammation Laceration Poisoning Puncture Respiratory Disorder / Disease Sprain / Strain Vision Loss Other N/A

  • No Physical Injury
  • Amputation
  • Asphyxiation
  • Burn
  • Concussion
  • Contusion
  • Crushing
  • Dermatitis
  • Dislocation
  • Electric Shock
  • Foreign Body
  • Fracture
  • Freezing
  • Hearing Loss or Impairment
  • Heat Illness
  • Hernia
  • Infection
  • Inflammation
  • Laceration
  • Poisoning
  • Puncture
  • Respiratory Disorder / Disease
  • Sprain / Strain
  • Vision Loss
  • Other
  • N/A

• Side of Body

  Right

  Left

  Both

• Part of Body

  Select Head / Skull / Brain Ear Eye Nose Teeth Mouth Neck Shoulder Upper Arm Elbow Lower Arm Wrist Hand Finger(s) Upper Back Lower Back Spine Chest Lungs Abdomen Pelvis Hip Groin Buttocks Upper Leg Knee Lower Leg Ankle Foot Toe(s) Other N/A

  • Head / Skull / Brain
  • Ear
  • Eye
  • Nose
  • Teeth
  • Mouth
  • Neck
  • Shoulder
  • Upper Arm
  • Elbow
  • Lower Arm
  • Wrist
  • Hand
  • Finger(s)
  • Upper Back
  • Lower Back
  • Spine
  • Chest
  • Lungs
  • Abdomen
  • Pelvis
  • Hip
  • Groin
  • Buttocks
  • Upper Leg
  • Knee
  • Lower Leg
  • Ankle
  • Foot
  • Toe(s)
  • Other
  • N/A

• Affected Employee Signature

  Sign

• Supervisor Signature

  Sign

Office Use Only

• Did the Employee Receive Medical Treatment

  Yes

  No

  N/A

• Did the Employee Return to Work?

  Yes

  No

  N/A

• Date Employee Returned to Work

  Date

• Treating Provider