Incident and Investigation information

Employee Section

  • What Time did the Incident occur

  • Name of Employee involved

  • Employee Title

  • Superviors Name

  • Employee Phone Number

  • Employee Address

  • Incident Location: Building/ Bay or Line/ Workstation number / Work Site

  • Incident Time

  • Incident Type

  • What was damaged?

  • Describe damages

  • What is the make, model, year and license plate number of the company vehicle?

  • Was local law enforcement called?

  • Name of the law enforcement agency the responded

  • Was police report filed?

  • What is the case number?

  • Was anyone else involved in the incident? Please list other driver information and include any other vehicles information including license plate, vin, make, model and year.

  • Name of person(s) involved

  • Addresses of person(s) Involved

  • Phone numbers of person(s) involved

  • Property that was damaged that person(s) own or was using

  • License plate or vin number or other identifying description of property

  • Were there any witnesses?

  • Name of witness(es)

  • Addresses of witness(es)

  • Phone numbers of witness(es)

  • Address where incident was located.

  • Who owns the property that was damaged?

  • What damages were caused?

  • Nature and extent of the loss, damage or misuse.

  • What actions have been taken to effect recovery or restitution?

  • What is the estimate of repairs or replacement? 2 estimates are needed.

  • Add photographs of the scene and damage

  • Add media

  • What Caught Fire?

  • Was there property damage?

  • What was damaged?

  • Describe Other

  • What Body Part was Caught?

  • Body Part Injured

  • What part of the head was injured?

  • What part of the arm was injured?

  • What part of the leg was injured?

  • What part of the torso was injured?

  • What part of the foot was injured?

  • Was there an amputation?

  • What part of the hand was injured?

  • Was there an amputation?

  • What chemical were you exposed to?

  • Body Part Exposed or Injured

  • What part of the head was injured?

  • Side of Body injured

  • What part of the arm was injured?

  • What part of the leg was injured?

  • What part of the torso was injured?

  • What part of the foot was injured?

  • Was there an amputation?

  • What part of the hand was injured?

  • Was there an amputation?

  • What chemical was spilled or released?

  • Body Part Injured

  • What part of the head was injured?

  • What side of the body was injuried?

  • What part of the arm was injured?

  • What side of the body was injuried?

  • What part of the leg was injured?

  • What side of the body was injuried?

  • What part of the torso was injured?

  • What side of the body was injuried?

  • What part of the foot was injured?

  • Was there an amputation?

  • What side of the body was injuried?

  • What part of the hand was injured?

  • Was there an amputation?

  • What side of the body was injuried?

  • Body Part Injured

  • What part of the head was injured?

  • What side of the body was injuried?

  • What part of the arm was injured?

  • What side of the body was injuried?

  • What part of the leg was injured?

  • What side of the body was injuried?

  • What part of the torso was injured?

  • What side of the body was injuried?

  • What part of the foot was injured?

  • Was there an amputation?

  • What side of the body was injuried?

  • What part of the hand was injured?

  • Was there an amputation?

  • What side of the body was injuried?

  • Body Part Injured

  • What part of the head was injured?

  • What side of the body was injuried?

  • What part of the arm was injured?

  • What side of the body was injuried?

  • What part of the leg was injured?

  • What side of the body was injuried?

  • What part of the torso was injured?

  • What side of the body was injuried?

  • What part of the foot was injured?

  • Was there an amputation?

  • What side of the body was injuried?

  • What part of the hand was injured?

  • Was there an amputation?

  • What side of the body was injuried?

  • What part of the body was exposed to bloodborne pathogens?

  • What side of the body was exposed?

  • Was the fall from a height?

  • how far did the EE fall?

  • Body Part Injured

  • What part of the head was injured?

  • What side of the body was injured?

  • What part of the arm was injured?

  • What side of the body was injured?

  • What part of the leg was injured?

  • What side of the body was injured?

  • What part of the torso was injured?

  • What side of the body was injured?

  • What part of the foot was injured?

  • Was there an amputation?

  • What side of the body was injured?

  • What part of the hand was injured?

  • What side of the body was injured?

  • Was there an amputation?

  • Body Part Injured

  • What part of the head was injured?

  • What side of the body was injured?

  • What part of the arm was injured?

  • What side of the body was injured?

  • What part of the leg was injured?

  • What side of the body was injured?

  • What part of the torso was injured?

  • What side of the body was injured?

  • What part of the foot was injured?

  • Was there an amputation?

  • What side of the body was injured?

  • What part of the hand was injured?

  • What side of the body was injured?

  • Was there an amputation?

  • Body Part Injured

  • What part of the head was injured?

  • What side of the body was injured?

  • What part of the arm was injured?

  • What side of the body was injured?

  • What part of the leg was injured?

  • What part of the torso was injured?

  • What side of the body was injured?

  • What part of the foot was injured?

  • Was there an amputation?

  • What side of the body was injured?

  • What part of the hand was injured?

  • What side of the body was injured?

  • Was there an amputation?

  • What happened that could have caused an incident?

  • Body Part Injured

  • What part of the head was injured?

  • What part of the arm was injured?

  • What side of the body was injured?

  • What part of the leg was injured?

  • What side of the body was injured?

  • What part of the torso was injured?

  • What side of the body was injured?

  • What part of the foot was injured?

  • Was there an amputation?

  • What side of the body was injured?

  • What part of the hand was injured?

  • What side of the body was injured?

  • Was there an amputation?

  • What side of the body was injured?

  • Body Part Injured

  • What part of the head was injured?

  • What part of the arm was injured?

  • What side of the body was injured?

  • What part of the leg was injured?

  • What side of the body was injured?

  • What part of the torso was injured?

  • What side of the body was injured?

  • What part of the foot was injured?

  • Was there an amputation?

  • What side of the body was injured?

  • What part of the hand was injured?

  • What side of the body was injured?

  • Was there an amputation?

  • What side of the body was injured?

  • Body Part Injured

  • What part of the head was injured?

  • What part of the arm was injured?

  • What side of the body was injured?

  • What part of the leg was injured?

  • What side of the body was injured?

  • What part of the torso was injured?

  • What side of the body was injured?

  • What part of the foot was injured?

  • Was there an amputation?

  • What side of the body was injured?

  • What part of the hand was injured?

  • What side of the body was injured?

  • Was there an amputation?

  • What side of the body was injured?

  • Was there a injury?

  • Body Part Injured

  • What part of the head was injured?

  • What part of the arm was injured?

  • What side of the body was injured?

  • What part of the leg was injured?

  • What side of the body was injured?

  • What part of the torso was injured?

  • What side of the body was injured?

  • What part of the foot was injured?

  • Was there an amputation?

  • What side of the body was injured?

  • What part of the hand was injured?

  • What side of the body was injured?

  • Was there an amputation?

  • In detail what excatly was the Employee doing right before the incident occured?

  • Description of Incident in detail.

  • In detail what did the employee do right after the incident?

  • What Equipment was the Employee using before during and after the incident?

  • What PPE was the EE wearing during the time of the incident? Please list in detail all PPE

  • Contributing Causes to Incident ( what do you think caused the incident to happen)

  • Were all best practices being used?

  • What could you have done differently?

  • Employee Signature

  • Date and Time

Leadership section

  • Incident description ( In detail describe what happened as explained to you by the employee and witnesses)

  • What contributing factors led to the incident

  • Was a safe work procedure used?

  • Had conditions changed to make the normal procedure unsafe?

  • Were the appropriate tools and materials available?

  • Were they used?

  • Were safety devices working properly?

  • Was lockout used when necessary?

  • Was there an equipment failure?

  • What caused it to fail?

  • Was the machinery poorly designed?

  • Was the machinery maintained properly?

  • Were hazardous products involved?

  • Were they clearly identified?

  • Was a less hazardous alternative product possible and available?

  • Should personal protective equipment (PPE) have been used?

  • Was the PPE used?

  • Were users of PPE properly educated and trained?

  • Was PPE clean and serviceable?

  • What were the weather conditions?

  • Was poor housekeeping a problem?

  • Was it too hot or too cold?

  • Was noise a problem?

  • Was there adequate light?

  • Were toxic or hazardous gases, dusts, or fumes present?

  • Was equipment properly inspected and maintained?

  • Did the worker follow the safe operating procedures?

  • Were workers experienced in the work being done?

  • Had they been adequately educated and trained?

  • Can they physically do the work?

  • Was EE using proper ergonomics to perform task?

  • Were they tired?

  • Was fatigue or shiftwork an issue?

  • Were they under stress (work or personal)?

  • Was there pressure to complete tasks under a deadline, or to by-pass safety procedures?

  • Did the EE violate Sabre policy or OSHA standard?

  • Was Horseplay involved?

  • Was the EE using all safety equipment and devices properly?

  • Did the EE report incident or injury immediately?

  • Were safety rules or safe work procedures communicated to and understood by all employees?

  • Were written procedures and orientation available?

  • Were the safe work procedures being enforced?

  • Was there adequate supervision?

  • Were workers educated and trained to do the work?

  • Had hazards and risks been previously identified and assessed?

  • Had procedures been developed to eliminate the hazards or control the risks?

  • Were unsafe conditions corrected?

  • Was regular maintenance of equipment carried out?

  • Had the condition or concern been reported beforehand?

  • Who was initially notified? (who in leadership was the first to know about the incident and arrive on the scene of the incidet?

  • Who in EHS was notified?

  • Date and Time EHS was notified

  • Who responded to the incident? ( all responders that are not EHS)

  • Who in EHS responded?

  • Was Medical care needed?

  • Was first aid provided by a certified first aid responder?

  • Who was the first aid provider?

  • Did the employee go for advance medical care outside the workplace?

  • Was maintenance needed?

  • Who in maintenance was notified?

  • Did Maintenance come to the scene?

  • When did maintenance arrive?

  • Initial Cost of Incident Estimate

  • What corrective actions are being taken?

  • Describe Elimination Plan

  • Describe Substitution Plan

  • What Engineering Controls will be put in place?

  • What Administrative Controls will be performed? (Training, Signage Etc.)

  • What PPE changes need to happen?

  • Who is responsible for corrective actions

  • When will corrective action be completed

  • Is training going to be done?

  • What is the topic of training?

  • Who is doing the training?

  • When is training being done?

  • What disciplinary actions is being taken?

  • When is disciplenary action being taken

  • When is disciplenary action being taken

  • When is disciplenary action being taken

  • When is disciplenary action being taken

  • When is disciplenary action being taken

  • Leadership Signature

  • Date and Time

EHS Section

  • Did the EE receive advance medical care by ambulance, hospital emergency department, urgent care or clinic

  • What facility did they go to?

  • When was advanced medical care given

  • Did the employee have any procedure not listed on the OSHA 1st aid list?

  • What procedure or physician order was done outside of the OSHA scope of 1st aid?

  • Did the EE receive a tetanus shot?

  • Was any diagnostic x-ray , cat scan or mri taken?

  • Did the EE take any over the counter medication?

  • What medication was given?

  • Was any Rx medication given?

  • What was Rx to the EE?

  • What was the treating physician's diagnosis?

  • Did the EE RTW full duty?

  • What restrictions were placed on the EE?

  • Was Physical Therapy ordered?

  • Is there an at work program that the EE can follow between appointments?

  • Was any drug testing done?

  • Why was testing not done?

  • What was the results of the test?

  • Was HR Notified?

  • Who in HR was notified?

  • Is there any follow up for the EE?

  • Where is the follow up?

  • When Is the follow up?

  • What physician is the EE following up with?

  • Will the EE follow up on site with anyone before the follow up with physician?

  • Who will the EE follow up with?

  • Was the employee admitted to the hospital for anything other than observation?

  • What was the admission diagnosis?

  • Who is the doctor that ordered the admission?

  • Incident Summary by step from injury to starting the task

  • Body Part Injuried

  • Equipment involved

  • Type of incident

  • 300 Log OSHA Recordable type

  • 300 Log OSHA Recordable Cause

  • 300 Log OSHA Recordable Cause

  • 300 Log OSHA Recordable Cause

  • 300 Log OSHA Recordable Cause

  • What is the severity (SE) of the injury or incident? (1-5)

  • What is the frequency (FE) of the task? (1-5)

  • What is the probability (PR) that the incident will happen again is nothing is done? (1-5)

  • What is the likelihood of detecting or avoiding (AV) an incident before it occurs? (1-5)

  • Risk Score ((SE*(FR+PR+AV)) (3-75)

  • EHS Recommended Actions

  • EHS Signature

  • Date and Time

Follow up

  • Name of peron following up

  • Has corrective actions been done?

  • What corrective action were completed?

  • Who completed corrective actions?

  • Completion date?

  • Has trainging been done?

  • What form of training was done?

  • Who did training?

  • Training completion date?

  • Was Disciplary action taken?

  • What was the level

  • Completion date

  • EHS Follow up signature

  • Time and Date

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