Pursuit Incident Report

• Investigation conducted on

  Date

• Prepared by

Incident Details

• Date & Time of Incident

  Date

• Incident Type (select all that apply)

  Select Injury Property Damage Near-Miss Theft Fire Spill over 5 Gallons

  • Injury
  • Property Damage
  • Near-Miss
  • Theft
  • Fire
  • Spill over 5 Gallons

• Was first aid administered?

  Yes

  No

• What kind of medical attention was administered?

  Select Medical Attention Declined CareSpot Urgent Care First Aid Ambulance

  • Medical Attention Declined
  • CareSpot Urgent Care
  • First Aid
  • Ambulance

• Was the incident reported at the time of injury?

  Yes

  No

Injuried Person Information

• Name of employee involved?

• Employee Number

• Employee Cell Phone Number

• Employee Job Title

• Employee Date of Birth

  Date

• Employee Hire Date

  Date

• How long has employee worked in current position?

• Where did the injury occur?

  Select

Incident Summary

• Describe what happened. Please be detailed but state only facts.

• Take photos of the injury, equipment or property involved. Take photos from the North, South, East, and West. Close up and further back.

  Media

• Does employee want to seek medical treatment beyond first aid?

  Yes

  No

Corrective Actions

• Are corrective/further actions required with regard to this incident?

  Yes

  No

• Please add any corrective actions to the appropriate questions above before completing this incident investigation

• undefined

Root Cause Analysis / Contributing Factors

• What were the contributing factors to this incident occurring? (select all that apply)

  Select Equipment Defects Unauthorized Equipment Use Improper Equipment Use Lack of protective safety devices Employee operating at inappropriate speed Equipment used outside rated capacity Lack of PPE Inappropriate PPE Untidy Conditions (Poor Housekeeping) Safety procedures not followed Inadequate ventilation Drugs or Alcohol

  • Equipment Defects
  • Unauthorized Equipment Use
  • Improper Equipment Use
  • Lack of protective safety devices
  • Employee operating at inappropriate speed
  • Equipment used outside rated capacity
  • Lack of PPE
  • Inappropriate PPE
  • Untidy Conditions (Poor Housekeeping)
  • Safety procedures not followed
  • Inadequate ventilation
  • Drugs or Alcohol

• A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident occurring and deeply understanding the underlying cause. One tactic to determine this is through asking "Why?" five times, to uncover the core of a problem.

• Has the root cause of this issue been able to be identified?

  Yes

  No

  N/A

• Why is the root cause for this issue unable to be identified at this time?

• How likely is this incident to reoccur in future?

  Select Certain Very Likely Likely Unlikely Very Unlikely Never Unclear / Not Determinable

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

• What is the root cause of this incident? Please consider and include all contributing factors

• Has the root cause of this issue been rectified or eliminated?

  Yes

  No

• How was the root cause rectified or eliminated?

• Please attach any relevant photos or media

  Media

• Please provide any relevant further details

• How likely is this incident to reoccur in future?

  Select Certain Very Likely Likely Unlikely Very Unlikely Never Unclear / Not Determinable

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

Sign Off

• Further action/follow-up/investigation required?

  Yes

  No

• Name & Signature of Investigator

  Sign