Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Supervisor's Incident Report and Investigation
To be completed by Area Supervisor or Manager
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Department
- Production
- Maintenance
- Shipping
- Receiving
- Inventory
- Administrative
- Pride & Polish
- EH&S
- Quality
- Beam Line
- Finishing
- Galvanizer
- Kettle
- Pre-Treat
- Racking
- Tool Room
- IT Department
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Supervisor:
- Travis Belleville
- Donnie Pretty
- Edward Dunn
- Braulio Rodriguez
- Edgar Torres
- Laurie Yaede
- Donald Williams
- Dustin Strouth
- Mike Shelman
- John Elder
- Dwayne Byxbe
- John Hungerford
- Jolene Zielinski
- Kenneth Moore
- Roger Elliott
- Louis Conde
- Chris Hale
- Anthony Patton
- Kenneth Tice
- Bill Campbell
- Chris Brown
- Kevin Tackett
- Billy Scott
- Pete Vornbrock
- Kevin Tackett
- Barry Holcombe
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Location of Incident:
- P1 B1
- P1 B2
- P1 B3
- P1 B4
- P1 B5
- P1 B6
- P1 B7
- P2 B1
- P2 B2
- P2 B3
- Maintenance
- West Plate Yard
- Yard
- East Shipping Yard
- South Test Site
- Parking Lot
- Plate Blast
- Galvanizing
- Bag Room
- Beam Bldg
- Beam Line
- Finished Goods
- Kettle
- Finishing
- Pole staging yard
- Pre Treat Room
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Type of incident:
- INJURY OR ILLNESS
- PROPERTY DAMAGE
- ENVIRONMENTAL RELEASE
- NEAR MISS
- PERSONAL MEDICAL
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Date of incident:
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Date reported:
INJURY OR ILLNESS
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Name of Injured:
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Part of Body Injured:
- Abdomen
- Ankle Left
- Ankle Right
- Arm Left
- Arm Right
- Back
- Brain
- Chest
- Digestive System
- Ear Left
- Ear Right
- Elbow Left
- Elbow Right
- Eye Left
- Eye Right
- Face
- Finger Left
- Finger Right
- Foot Left
- Foot Right
- Hand Left
- Hand Right
- Head
- Heart
- Hips
- Kidney, Bladder, Intestine
- Knee Left
- Knee Right
- Leg Left
- Leg Right
- Lungs
- Multiple Parts
- Shoulder Left
- Shoulder Right
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Occupation:
- Welder
- Welder Fitter
- Material Handeler
- Quality Control
- Lead
- Plate Locator
- Long Seam Operator
- Machine Operator
- Pride and Polish
- Mechanic
- Maintenance Technician
- Supervisor
- Manager
- EH&S Specialist
- Special Projects
- Inventory Control
- Administrative
- Shuttle Lift Operator
- Shipping Spec.
- Parts Coordinator
- Mule Driver
- Computer Technician
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Add media
Property Damage
Property Damage
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Nature of Incident:
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Nature of Damage:
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Estimated Cost:
- 0.00 to 50.00 Dollars
- 51.00 to 100.00 Dollars
- 101.00 to 150.00 Dollars
- 151.00 to 200.00 Dollars
- 201.00 to 250.00 Dollars
- 251.00 to 300.00 Dollars
- 301.00 to 350.00 Dollars
- 351.00 to 400.00 Dollars
- 401.00 to 450.00 Dollars
- 451.00 to 500.00 Dollars
- 501.00 to 600.00 Dollars
- 601.00 to 700.00 Dollars
- 701.00 to 800.00 Dollars
- 801.00 to 900.00 Dollars
- 901.00 to 1000.00
- 1001.00 or Greater
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Object/Equipment/Substance Fault
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Name of person(s) with most control:
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Loss Severity Potential:
- Major
- Serious
- Minor
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ENVIRONMENTAL RELEASE
ENVIRONMENTAL RELEASE
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Nature of Incident:
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Incident Cost if Applicable:
- 0.00 to 50.00 Dollars
- 51.00 to 100.00 Dollars
- 101.00 to 150.00 Dollars
- 151.00 to 200.00 Dollars
- 201.00 to 250.00 Dollars
- 251.00 to 300.00 Dollars
- 301.00 to 350.00 Dollars
- 351.00 to 400.00 Dollars
- 401.00 to 450.00 Dollars
- 451.00 to 500.00 Dollars
- 501.00 to 600.00 Dollars
- 601.00 to 700.00 Dollars
- 701.00 to 800.00 Dollars
- 801.00 to 900.00 Dollars
- 901.00 to 1000.00
- 1001.00 or Greater
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Person Reporting Incident:
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Object / Equipment / Substance Fault:
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Person With Most Control:
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Probability of Occurance:
- Frequent
- Occasional
- Seldom
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INCIDENT DESCRIPTION
INCIDENT DESCRIPTION:
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Describe How the Event Occured:
CAUSES: What Actions and Conditions Caused the Event?
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Unsafe Acts:
- Operating Equip. without authority
- Failure to warn
- Failure to secure
- Operating at Improper speed
- Making safety devices inoperable
- Removing safety devices
- Using equipment improperly
- Failure to use proper PPE
- Failure to correctly use PPE
- Using defective equipment
- Improper loading
- Improper material placement
- Improper lifting
- Improper position for task
- Servicing equip. while in operation
- Horseplay
- Under influence of alcohol and/or drugs
- Failure to follow rules
- Failure to use proper/ available equipment
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Unsafe Conditions
- Inadequate guards or barriers
- Inadequate or improper protective equipment
- Defective tools, equipment or materials
- Congestion or restricted action
- Inadequate warning system
- Fire and explosion hazards
- Poor housekeeping; disorder
- Hazardous environmental conditions: gases, dusts, smokes, fumes, vapors
- Noise exposures
- Radiation exposures
- High or low temperature exposures
- Inadequate or excess illumination
- Inadequate ventilation
- Poor design/ layout causing awkward body positioning
OTHER FACTORS
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What specific Personal or Job Factors Caused or Could Cause This Event?
- inadequate capability
- Lack of knowledge
- Lack of skill
- Lack of training
- Life stress
- Improper Motivation
- Lack of supervision
- Poor engineering
- Poor planning
- Poor purchasing
- Poor maintenance
- Poor tools/ equipment
- Poor work standards
- Wear and tear
- Abuse or misuse
TYPE OF CONTACT
TYPE OF CONTACT
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TYPE OF CONTACT
- Struck against
- Struck by
- Caught in
- Caught on
- Caught between
- Slip
- Fall on same level
- Fall to lower level or elevation
- Overexertion
- Exposure
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CONTACT WITH
- Electricity
- Heat / Exposed fire
- Hot metal
- Dusts
- Acids or Caustics
- Hazardous Chemicals
- Moving hoisted load
- Sharp edges
- Heavy pinch point / roll-over
- High noise
- Hazardous Light
SUPERVISOR'S CORRECTIVE ACTIONS:
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What will be done to control the causes listed and prevent reoccurrence?
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Signature of Supervisor:
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Select date
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Signature of Employee:
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Select date
EHS REVIEW: To be completed by HR or Safety
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I concur with Supervision's corrective or remedial actions.
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After review I recommend the following corrective and/or remedial actions or add these comments:
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EHS/ HR COMMENTS
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Name and signature of Safety Representative
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Select date
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Incident Classification
- Non-Injury Event
- First Aid
- OSHA Recordable
- Not Work Related