Information
OSHA NON-MANDATORY INVESTIGATIVE TOOL
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CLIENT:
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Site or job number
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Conducted on
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Prepared by
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Location
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Personnel
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Investigator signature
NON-MANDATORY INVESTIGATIVE TOOL
A. ESTABLISHMENT INFORMATION:
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1] NAME OF CONTACT:
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2] JOB TITLE:
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3] NAME OF COMPANY:
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4] ADDRESS:
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5] CONTACT PHONE:
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6] FAX:
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7] EMAIL:
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8] FEDERAL TAX ID # / NAICS #:
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9] HOW MANY EMPLOYEES AT WORK SITE
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9B] HOW MANY EMPLOYEES AT ALL LOCATIONS:
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10] Owner / Corp Officers
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10] UNION?
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11] UNION NAME AND CONTACT INFORMATION:
INJURY?
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INJURY?
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9] NATURE OF INJURY:
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Is injured directly employed or controlled by client
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Injured worker employed by:
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1] INJURED EMPLOYEE NAME:
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2] AGE:
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3] GENDER:
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4] EMPLOYEE TYPICAL JOB TITLE:
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[FOR ADDITIONAL EMPLOYEES USE CONTINUATION SECTION AT END OF FORM]
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5] JOB AT TIME OF INCIDENT:
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8] AMOUNT OF TIME IN CURRENT POSITION AT TIME OF INCIDENT:
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7] LENGTH OF EMPLOYMENT WITH THE COMPANY:
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3] WHAT WAS EMPLOYEE DOING JUST BEFORE ACCIDENT OCCURRED?
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6] TYPE OF EMPLOYMENT [CHECK ALL THAT APPLY]
- FULL TIME
- PART TIME
- SEASONAL
- TEMPORARY
- OTHER
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6] WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE?
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5] WHAT WAS THE INJURY OR ILLNESS:REASON FOR VISIT
C. INCIDENT INVESTIGATION:
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INCIDENT ONLY ? [NO INJURY]
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2] LOCATION OF INCIDENT:
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1] Date and time of incident
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4] WHAT HAPPENED?
D. WHAT CAUSED OR ALLOWED THIS INCIDENT TO HAPPEN?
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1] HAZARDOUS CONDITION[S] IDENTIFIED AND CORRECTIVE ACTION TAKEN BY EMPLOYER.
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2] ADDITIONAL NOTES AND COMMENTS.
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3] DATE HAZARDOUS CONDITION WAS ABATED:
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EMPLOYER NAME:
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ADDITIONAL PREVENTIVE MEASURES THAT SHOULD BE TAKEN TO PREVENT SIMILAR INCIDENTS
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NOTE:
This investigation tool is to assist in finding the cause and preventing similar incidents in the future.
EMPLOYERS SIGNATURE
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Employer:
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Employers signature
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THIS CONSTITUTES MY ELECTRONIC SIGNATURE. [ if box is checked, this submission shall be considered as an authorized written signature]
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Date Signed
