PRC Building Services Pty Ltd

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Only fill Out Section Pertaining To The Incident

• Incident Type

  Select Near Miss Property Damage First Aid Environmental Medical Treatment Serious Injury

  • Near Miss
  • Property Damage
  • First Aid
  • Environmental
  • Medical Treatment
  • Serious Injury

Investigation Report

• Company (Select Option)

  Acorn Industrial

  Hard Hat

  Hire Alternatives

• Date and Time of Accident

  Date

• Exact Location of Accident

• Employee Name

• Incident Number

• Job Title

• Date Hired (mm/dd/year)

General Information

• Is this the employees first incident

  Yes

  No

  N/A

• If not, how many?

• Where was the incident located

  On Acorn Property

  In transit to / from job

  On Customer Property

  Specific job site (please list job name and number)

• Job Name and Number

• How many hours had employee worked this shift

Description of the Accident/Damage

• Please describe what happened, in detail.

• Photo of accident area. Please provide as many as needed.

  Media

Accidents /Incidents Conditions Involved

• Employee Job Description

  Select Administrative / Office Sales Fabrication / Welding Shop Mechanical Controls / Troubleshooting Maintenance Installation Fire Protection Plumbing Piping Sheet Metal Electrical Engineering Construction

  • Administrative / Office
  • Sales
  • Fabrication / Welding Shop
  • Mechanical
  • Controls / Troubleshooting
  • Maintenance
  • Installation
  • Fire Protection
  • Plumbing
  • Piping
  • Sheet Metal
  • Electrical
  • Engineering
  • Construction

• Hazardous Condition

  Select Improperly or Inadequately Guarded Unguarded Defective Tools Unsafe Design or Construction Improper Lighting Improper Ventilation Poor Housekeeping Congested Area No Unsafe Condition Other (specify below)

  • Improperly or Inadequately Guarded
  • Unguarded
  • Defective Tools
  • Unsafe Design or Construction
  • Improper Lighting
  • Improper Ventilation
  • Poor Housekeeping
  • Congested Area
  • No Unsafe Condition
  • Other (specify below)

• Please describe if "Other"

• Severity of Treatment

  First Aid Only (non-OSHA Recordable)

  Medical Only (non-OSHA Recordable)

  Restricted Work (No lost days)

  Lost Time

  Near Miss

• Was injured employee Hospitalized?

  Yes

  No

  N/A

Property Damage - Complete and scroll down to Root Cause Analysis if over $1000 damage

• What was the contributing factors

  Inatention

  Negelingence

  unlicensed operator

  fatigue

  complacency

• Write Description Of Incident

• Property Damaged Type

  Select Vehicle Plant Building Grounds Machinery Tooling Homeowners/Tenants Property

  • Vehicle
  • Plant
  • Building
  • Grounds
  • Machinery
  • Tooling
  • Homeowners/Tenants Property

• Estimated Cost of Damage

• Photo Damage

  Media

• Mark location of damage or sketch

  Drawing
• Locate Area
  Address

Body Part Injured

• Eye(s)

  Left

  Right

  Both

• Arm(s)

  Left

  Right

  Both

• Elbow

  Left

  Right

  Both

• Wrist

  Left

  Right

  Both

• Hand

  Left

  Right

  Both

• Buttocks

  Left

  Right

  Both

• Leg(s)

  Left

  Right

  Both

• Foot

  Left

  Right

  Both

• Knee

  Left

  Right

  Both

• Ankle

  Left

  Right

  Both

• Back

  Yes

  No

  N/A

• Lungs / Throat / Mouth

  Yes

  No

  N/A

• Chest / Ribs

  Yes

  No

  N/A

• Abdomen

  Yes

  No

  N/A

• Groin / Genitals

  Yes

  No

  N/A

• Head / Neck

  Yes

  No

  N/A

• Face

  Yes

  No

  N/A

• Finger(s)

  Yes

  No

  N/A

• Toe(s)

  Yes

  No

  N/A

Unsafe Act & Other Contributing Factors

• Operating without Authority

  Yes

  No

  N/A

• Unsafe Carrying / Lifting

  Yes

  No

  N/A

• Taking Unsafe Position

  Yes

  No

  N/A

• Failure to use PPE or improper use of PPE

  Yes

  No

  N/A

• Failure to Secure Equipment

  Yes

  No

  N/A

• Equipment Failure

  Yes

  No

  N/A

• Poor or Inadequate Housekeeping

  Yes

  No

  N/A

• Operating at Unsafe Speed or Beyond Capacity

  Yes

  No

  N/A

• Congested Area

  Yes

  No

  N/A

• Accident Caused by Another Employee

  Yes

  No

  N/A

• Other (Specify)

Nature of Injury

• Foreign Object

  Yes

  No

  N/A

• Cut

  Yes

  No

  N/A

• Bruise / Contrusion

  Yes

  No

  N/A

• Sprain / Strain

  Yes

  No

  N/A

• Fracture

  Yes

  No

  N/A

• Burn (Chemical)

  Yes

  No

  N/A

• Burn (Thermal)

  Yes

  No

  N/A

• Chemical Irritation

  Yes

  No

  N/A

• Amputation

  Yes

  No

  N/A

• Puncture Wound

  Yes

  No

  N/A

• Hernia

  Yes

  No

  N/A

• Dermatitis

  Yes

  No

  N/A

• Smashed / Pinched

  Yes

  No

  N/A

• Abrasion

  Yes

  No

  N/A

• Infection

  Yes

  No

  N/A

• Secondary infection

  Yes

  No

  N/A

Accident Type

• Struck By / Against

  Yes

  No

  N/A

• Caught In / Out / Between

  Yes

  No

  N/A

• Fall (Same Level)

  Yes

  No

  N/A

• Fall (Different Level) Height:

  Yes

  No

  N/A

• Slip / Trip

  Yes

  No

  N/A

• Vehicle Accident

  Yes

  No

  N/A

• Contact with Temperature Extremes

  Yes

  No

  N/A

• Repetitious Trauma

  Yes

  No

  N/A

• Over Exertion

  Yes

  No

  N/A

• Chemical Exposure

  Yes

  No

  N/A

• Skin

  Yes

  No

  N/A

• Inhalation

  Yes

  No

  N/A

Protective Equipment

• Required but NOT in Use

  Yes

  No

  N/A

• Required and IN Use

  Yes

  No

  N/A

• Not Required (May have reduced injury)

  Yes

  No

  N/A

• Not Required (would NOT have effected injury)

  Yes

  No

  N/A

• Specify Protective Equipment in Use

Actions to Prevent Accident / Incident Re-OCCURANCE

• Restriction of Person(s) Involved

  Yes

  No

  N/A

• Reprimand of Person(s)Involved

  Yes

  No

  N/A

• Discipline of Person(s) Involved

  Yes

  No

  N/A

• Action to Improve Inspection or Monitoring

  Yes

  No

  N/A

• Action to Improve Construction

  Yes

  No

  N/A

• Investigate Better Method

  Yes

  No

  N/A

• Action to Improve Clean Up

  Yes

  No

  N/A

• Request Job Safety Analysis to be Done

  Yes

  No

  N/A

• Equipment Replacement or Repair

  Yes

  No

  N/A

• Action to Improve Design

  Yes

  No

  N/A

• Installation of Guard or Safety Device

  Yes

  No

  N/A

• Request Pre-Job Instructions

  Yes

  No

  N/A

• Correction of Unnecessary Congestion

  Yes

  No

  N/A

• Improve PPE

  Yes

  No

  N/A

• Inform Other Supervision

  Yes

  No

  N/A

• Request Safety Observation

  Yes

  No

  N/A

Root Cause(s)- Anaylis

• List any and ALL Root Causes

Indirect Cause(s)

• List any and ALL Indirect Causes

Recommended Corrective Action(s)

• ALL above listed items MUST be explained HOW reoccurrence will be prevented

Sign Off

• Individual assigned responsibility for carrying out measures for preventing reoccurrence.

  Sign

• Date Corrective Action(s) to be completed

  Date

• Project Manager

  Sign

• Safety Representative

  Sign