RHL Accident/Incident Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select date

  Date

• Department

INJURED PERSON

• Name:

• Address:
  Address

• Age:

• Phone:

• Job Title:

• Length of Employment at Company:

• Length of Employment at Job:

• Supervisor Name:

Employee Classification:

• Full Time

• Part Time

• Contract

• Temporary

Nature of Injury

• Strain/Sprain

• Fracture

• Laceration/Cut

• Bruising

• Scratch/Abrasion

• Amputation

• Burn/Scald

• Dislocation

• Internal

• Foreign Body

• Chemical Reaction

• Other

• Specify

• Injured Body Part

• Remarks

Treatment

• First Aid

• Emergency Room

• Dr.'s Office

• Hospitalization

• Name and Address of Treating Physician or Facility:

DAMAGED PROPERTY

• Property, Equipment, or Material Damaged:

• Object or Substance Inflicting Damage:

• Describe Damage:

INCIDENT DESCRIPTION

• Describe what happened (attach photographs or diagrams if necessary below):

• Add media

  Media

• Add drawing

  Drawing

ROOT CAUSE ANALYSIS (Check all that apply)

Unsafe Acts

• Improper Work Technique

• Safety Rule Violation

• Improper PPE or PPE not used

• Operating Without Authority

• Failure to Warn or Secure

• Operating at Improper Speeds

• By-passing Safety Devices

• Guards Not Used

• Improper Loading or Placement

• Improper Lifting

• Servicing Machinery in Motion

• Horseplay

• Drug or Alcohol Use

• Unnecessary Haste

• Unsafe Act of Others

• Other

Unsafe Conditions

• Poor Workstation Design/Layout

• Congested Work Area

• Hazardous Substances

• Fire or Explosion Hazard

• Inadequate Ventilation

• Improper Material Storage

• Improper Tool or Equipment

• Insufficient Knowledge of Job

• Slippery Conditions

• Poor Housekeeping

• Excessive Noise

• Inadequate Hazards Guarding

• Defective Tools/Equipment

• Insufficient Lighting

• Inadequate Fall Protection

• Other:

Management Deficiencies

• Lack of Written Policies & Procedures

• Safety Rules Not Enforced

• Hazards Not Identified

• PPE Unavailable

• Insufficient Worker Training

• Insufficient Supervisor Training

• Improper Maintenance

• Inadequate Supervision

• Inadequate Job Planning

• Inadequate Hiring Practices

• Inadequate Workplace Inspection

• Inadequate Equipment

• Unsafe Design or Construction

• Unrealistic Scheduling

• Poor Process Design

• Other:

ACCIDENT/INCIDENT ANALYSIS

• Using the root cause analysis list, explain the cause(s) of the incident in as much detail as possible.

• Make sketches or illustrations to help describe incident:

  Drawing

• How bad could the accident have been?

  Select Very Serious Serious Minor

  • Very Serious
  • Serious
  • Minor

• What is the chance of the accident happening again?

  Frequent

  Occasional

  Rare

PREVENTIVE ACTIONS

• Describe actions that will be taken to prevent recurrence:

• Deadline

• By Whom

• Complete

INVESTIGATION TEAM

• Name and Position

  Sign

• Name and Position

  Sign

• Name and Position

  Sign

• Name and Position

  Sign