ROOT CAUSE INVESTIGATION / OSHA 301 FORM

• Jobsite:

  Select

• Insurance Coverage:

  Select

• Claim Number:

• General Contractor:

  Select

• Project Superintendent:

  Select

• Project Manager:

  Select

• Weather (Take Screenshot from Heat Index App):

  Media

• Contacted Tom Isola @ 407.607.5111

  Yes

  No

• Number of Employees:

Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes.

COMPLETED BY

• Completed By:

  Select

• Title:

  Select

• Date:

  Date

INFORMATION ABOUT THE EMPLOYEE

• 1) First Name:

• Middle Name:

• Last Name

• 2) Street:

• Apt#:

• City:

• State:

• Zip:

• 3) Date of Birth:

  Date

• 4) Date of Hire:

  Date

• 5) Male of Female:

  Select

• Social Security Number:

• Employee Number:

INFORMATION ABOUT THE PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL

• Medical Attention Required:

  Yes

  No

• 6) Name of Physician or other Health Care Professional (Located on DWC-25 Bottom Left of Second Page):

• 7) If Treatment was Given Away From the Worksite, Where was it Given:

  Select

• Street:

• City:

• State:

  Select

• Zip:

• Transportation and/or Translation Needed for Future Visits:

  Select

• Work Status:

  Select

• Drug Screen Conducted:

  Yes

  No

• THIS IS REQUIRED. CALL TOM ISOLA WITH ANY QUESTIONS

• 8) Was Employee Treated in an Emergency Room:

  Yes

  No

• How Was the Employee Transported:

  Select

• 9) Was Employee Hospitalized Overnight: as an in-patient:

  Yes

  No

INFORMATION ABOUT THE CASE:

• 10) Case Number from the Log:

• (Transfer the case number from the Log after you record the case.)

• 11) Date of Injury or Illness:

  Date

• 12) Time Employee Began Work:

  Date

• 13) Time of Event:

  Date

• Re fields 14 to 17: Please do not include any personally identifiable information (PII) pertaining toworker(s) involved in the incident (e.g., no names, phone numbers, or Social Security numbers).

• 14) What Was the Employee Doing Just Before the Incident Occurred:

• Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: “climbing a ladder while carrying framing materials”; “spraying form oil from pump can”; “moving material with crane”

• 15) What Happened? Tell us How the Injury Occurred:

• Examples: "When ladder slipped on concrete slab, worker fell 12 feet”; “Worker was sprayed with form oil in face while spraying forms”; “Finger caught between skip pan and dumpster.”

• 16) What was the Injury or Illness:

  Select

• Examples: “fractured wrist”; “chemical burn, eyes”; “bruised finger.”

• 17) What object or substance directly harmed the Employee:

• Examples: “concrete slab”; “form oil”; “skip pan” If this question does not apply to the incident, leave it blank.

• 18) If the Employee Died, When did Death Occur:

  Date

INJURY DETAILS

• Injury Cause / Source:

  Select

• Date & Time Incident Reported:

  Date

• Person Reported to:

• Did the Injury Occur in Course of Employment:

  Yes

  No

• Day of the Week:

  Select

• What Part of Employee’s Workday Did the Incident Occur:

  Select

• Was the Employee Working:

  Select

• Rate the Pain from a Scale of 1-10:

• Pictures of Accident:

  Media

BODY INJURIES

BODY AREA #1

• Area of Body:

  Select

• Left or Right:

  Select

BODY AREA #2

• Area of Body:

  Select

• Left or Right:

  Select

WITNESSES

• Name & Phone #

• Name & Phone #

• Name & Phone #

CORRECTIVE ACTIONS

• HOW CAN FUTURE INCIDENTS BE PREVENTED?

  Select

CONTRIBUTING FACTORS

• 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.

• Languages Spoken:

  Select

• Occupation:

  Select

• Time in Occupation at Time of Accident:

  Select

• Name of Foreman Responsible:

• Was the worker following the guidelines to the specific job task?

  Yes

  No

• Was a Pre-Task completed for this work procedure?

  Yes

  No

• Did the foreman and crew discuss a detailed work plan?

  Yes

  No

• Did the work plan address the identified hazard(s)?

  Yes

  No

• Were the tools and equipment right for the job?

  Yes

  No

• Was the employee capable, trained, and qualified to do this work?

  Yes

  No

• Was there enough time to do the task safely?

  Yes

  No

• Does the employee normally do this task?

  Yes

  No

• Was human factor such as the person’s size or strength a factor?

  Yes

  No

• Did the sun, heat, cold, dust, glare, fatigue contribute to the incident?

  Yes

  No

• Was the injury a result of the Pre-Task not being followed?

  Yes

  No

• Was the worker a new hire (GREEN TAPE) or a transfer (RED TAPE)?

  Select

• Was a Safety Rule of Specific Instruction Violated?

  Yes

  No

• Why Did it Happen - Unsafe Acts of People:

  Select

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

  Select Drugs or Alcohol Employee Operating at Inappropriate Speed Equipment Used Outside Rated Capacity Improper Equipment Use Inappropriate PPE Inadequate Ventilation Inadequate Guard Lack of PPE Not Aware of Surroundings No Training or Insufficient Personal Issue Safety procedures not followed Tool or Equipment Defective Unauthorized Equipment Use Unguarded Hazard Unsafe Clothing Unsafe Lighting Untidy Conditions (Poor Housekeeping) Weather Related

  • Drugs or Alcohol
  • Employee Operating at Inappropriate Speed
  • Equipment Used Outside Rated Capacity
  • Improper Equipment Use
  • Inappropriate PPE
  • Inadequate Ventilation
  • Inadequate Guard
  • Lack of PPE
  • Not Aware of Surroundings
  • No Training or Insufficient
  • Personal Issue
  • Safety procedures not followed
  • Tool or Equipment Defective
  • Unauthorized Equipment Use
  • Unguarded Hazard
  • Unsafe Clothing
  • Unsafe Lighting
  • Untidy Conditions (Poor Housekeeping)
  • Weather Related

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

  Yes

  No

• How Likely is This Incident to Reoccur in the Future?

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

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