Safety - Accident Investigation Report

• Document No.

• Audit Title (initials of injured associate-mm-dd-yy)

• Date and Time of Incident

  Date

• Accident Incident Investigation Form Prepared by (full name, employee ID, position)

• Date and Time Accident Incident Investigation Form was initiated

  Date

• Area / Location of Accident

  Select Shipping/Recieving Sheeting Press Room Finishing Maintenance QA Ink Room Plateroom Break areas Rest Rooms Office Areas Outside Grounds Vehicle

  • Shipping/Recieving
  • Sheeting
  • Press Room
  • Finishing
  • Maintenance
  • QA
  • Ink Room
  • Plateroom
  • Break areas
  • Rest Rooms
  • Office Areas
  • Outside Grounds
  • Vehicle

ASSOCIATE INJURED INFO

• Full Name

• Address. City. State. Zip code

• Phone number

• Social Security #

• Hire Date mm-dd-yyyy

• Gender

  Male

  Female

PERSONAL INFORMATION (injured employee)

• Time associate reported to work on date of incident?

• Enter date and time of injury or accident

  Date

• Take picture of 1.) Incident Report. 2.) Page 1 FDC Incident/ Investigation Report

  Media

Manager / Safety Team Interview

• Was blooded present?

  Yes

  No

  N/A

• Who, if anyone, provided first aid to the injured?

• Employment Category

  Full time

  Part time

  Contractor

  Visitor

• Length of employment

  less than 1 month

  > 1 to 6 months

  > 6 months to 1 year

  1 year to 5 years

  > 5 years

• Time in occupation at time of incident

  less than 1 month

  > 1 to 6 months

  > 6 months to 1 year

  1 year to 5 years

  > 5 years

• Type of operation

  Select Production Maintenance Set Up Cleaning Unjamming Other

  • Production
  • Maintenance
  • Set Up
  • Cleaning
  • Unjamming
  • Other

• Was this operation a regular part of employees job?

  Yes

  No

  N/A

• Type of injury

  Select No Injury First Aid Medical Treatment Lost Days Restricted Days Fatality

  • No Injury
  • First Aid
  • Medical Treatment
  • Lost Days
  • Restricted Days
  • Fatality

• Does equipment have lockable disconnect?

  Yes

  No

  N/A

• Name and title of person who assigned task/job

ACCIDENT / INCIDENT SUMMARY

• How long since a supervisor was in area of incident and who?

• We're there any witnesses to the incident? What are the witnesses names?

Accident Sequence - describe in reverse order the occurrence of events preceding the injury

• Injury Event / Accident Event

• Describe the preceding events that led up to the injury or accident

Preceding Events

• Was PPE required for this task?

  Yes

  No

  N/A

• What PPE was required and in use at time of incident

PPE REQUIRED

• Provided?

  Yes

  No

  N/A

• Trained on proper use?

  Yes

  No

  N/A

• Proper use of PPE?

  Yes

  No

  N/A

• PPE use enforced by manager and supervisor?

  Yes

  No

  N/A

• Was equipment adequately guarded? If no describe deficiency

  Yes

  No

  N/A

• Has employee received training prior to job assignment?

  Yes

  No

  N/A

• Who performed training?

• What was the duration of the training?

• Was training adequate?

  Yes

  No

  N/A

• Was lockout necessary?

  Yes

  No

  N/A

• Was employee trained?

  Yes

  No

  N/A

• Add media

  Media

• Was training adequate?

  Yes

  No

  N/A

• Was lock provided?

  Yes

  No

  N/A

• Yes

  No

  N/A

• Was written procedure required?

  Yes

  No

  N/A

• Was procedure provided to follow?

  Yes

  No

  N/A

QUESTIONNAIRE

• Where were you at the time of the incident?

• What time did the incident occur?

• What were you doing at the time of the incident

• What injury resulted from the incident?

• Was there any ergonomic (strain/sprain) from the incident?

  Yes

  No

  N/A

• We're any Pre-existing conditions with the injury area?

  Yes

  No

  N/A

• If moving a object what was the estimated weight?

• Did you ask for help with lifting?

  Yes

  No

  N/A

• Demonstrate how the task was performed

• Could you have done anything different to prevent the injury?

• Was there a laceration incident

  Yes

  No

  N/A

• What type of equipment or tool was used?

• We're there any know issues with the equipment/tool not functioning properly?

  Yes

  No

  N/A

• Demonstrate how the task was performed

• Could you have done anything different to prevent the injury?

  Yes

  No

  N/A

• Was there a trauma incident?

  Yes

  No

  N/A

• Did a trip, slip, bump, falling object cause the incident?

  Yes

  No

  N/A

• Was a ladder involved?

  Yes

  No

  N/A

• What type?

• Where were your feet placed on the ladder?

• Was the ladder inspected as part of the Fall Protection Program?

  Yes

  No

  N/A

• We're there any safety restraints in place?

  Yes

  No

  N/A

• Demonstrate how the task was performed

• How could this incident been prevented?

• How often do you perform this task?

• Are there any specific PPE requirements for the task and were they used?

• Was training provided for this task?

  Yes

  No

  N/A

• Were any safety mechanisms by-passed?

  Yes

  No

  N/A

• After your involvement with this incident, is there any insight you could share or preventative actions you would recommend?

CONCLUSION / ROOT CUASE

• Enter conclusions

CORRECTIVE ACTIONS REQUIRED

• Enter all correct preventative actions that will be implemented

PICTURES & DRAWINGS

• Take pictures of injury/accident including body part(s), location, equipment, tools, etc.

  Media

• Add drawing

  Drawing

SIGN and DATE

• Name / Signature of Employee (required)

  Sign

• Name / Signature of Supervisor / Lead

  Sign

• Name / Signature of Department Manager (required)

  Sign

• Name / Signature of Safety Team Lead (required)

  Sign