SLC Incident Investigation Report

• Site conducted

  Select

• Incident/Case No.

• Type of Incident

  Property Damage

  First Aid Incident

  Medical Treatment

• Conducted on

  Date

• Prepared by

1. General Information

• Injure Employee

• Job Title

• Employee ID

• Supervisor

• Type of Employment

  Regular FT

  Temporary

  Contract

• Shift

• Time Employee Began Shift

• Date and Time of Injury

  Date

• Date and Time First Reported

  Date

• Witness (1)

• Job Title

• Witness (1)

• Job Title

• Business Area (select one)

  Select Honeycomb Roller Shades Shutters Maintenance Warehouse Parts Repairs Engineering Office Other

  • Honeycomb
  • Roller Shades
  • Shutters
  • Maintenance
  • Warehouse
  • Parts
  • Repairs
  • Engineering
  • Office
  • Other

• Specify Other Business Area

• Product Type (select if applicable)

  Honeycomb

  Roller Shades

  Shutters

• Department (Assembly, Rail, etc.)

• Exact Location (Equipment ID, Room, Pole, etc.)

2. Incident Information

Part A. Injured Employee Description - in their own words

• Events Prior to Injury

• Description of Incident

• Events After

Part B. Witness Description - in their own words

• Witness Name

• Events Prior to Injury

• Description of Incident

• Events After

Part C. Manager/Supervisor/Comments

• Events leading up to injury, observations, etc.

Part D. Incident Type

• Type of Incident

  Select Exposure to/contact with Fall from height/same level Fire/Explosion Harmful substance Illness Overexertion Repetitive motion Slip Struck by/Against Transportation accident Trapped / caught by Trip Use of hand tool Workplace violence Material handling (e.g. lifting, carrying) Bodily Reaction Other

  • Exposure to/contact with
  • Fall from height/same level
  • Fire/Explosion
  • Harmful substance
  • Illness
  • Overexertion
  • Repetitive motion
  • Slip
  • Struck by/Against
  • Transportation accident
  • Trapped / caught by
  • Trip
  • Use of hand tool
  • Workplace violence
  • Material handling (e.g. lifting, carrying)
  • Bodily Reaction
  • Other

• Please specify Other Type of Incident

Part E. Injury

• Nature of Illness/Injury: (Check one)

  Select Abrasion Amputation Bite Broken Bone Bruise Burn Chemical Contamination Concussion Cut (Minor) Cut (Stitches or Sutures) Dislocation Electric Shock Fatality Foreign Body Penetrating Hearing Loss Inflammation Irritation Loss of Consciousness Musculoskeletal Disorder MSD Poisoning Respiratory Condition Skin Disorder Smoke or Fume Inhalation Sprain Strain Limb Disorder (TDS, CTS) Other

  • Abrasion
  • Amputation
  • Bite
  • Broken Bone
  • Bruise
  • Burn
  • Chemical Contamination
  • Concussion
  • Cut (Minor)
  • Cut (Stitches or Sutures)
  • Dislocation
  • Electric Shock
  • Fatality
  • Foreign Body Penetrating
  • Hearing Loss
  • Inflammation
  • Irritation
  • Loss of Consciousness
  • Musculoskeletal Disorder MSD
  • Poisoning
  • Respiratory Condition
  • Skin Disorder
  • Smoke or Fume Inhalation
  • Sprain
  • Strain
  • Limb Disorder (TDS, CTS)
  • Other

• Please specify Other Nature of Illness/Injury

• Body Part (select all that apply)

  Select Back- Lower Back- Upper Head Ear - Left Ear - Right Eye - Left Eye - Right Nose Mouth Face Neck Chest Ribs Abdomen Groin Internal Shoulder - Left Shoulder - Right Upper Arm - Left Upper Arm - Right Elbow - Left Elbow - Right Lower Arm - Left Lower Arm - Right Wrist - Left Wrist - Right Hand - Left Hand - Right Finger - 1st Finger - 2nd Finger - 3rd Finger - 4th Finger - 5th Buttocks/Pelvis Upper Leg - Left Upper Leg - Right Knee - Left Knee - Right Lower Leg - Left Lower Leg - Right Ankle - Left Ankle - Right Foot - Left Foot - Right Toe - 1st Toe - 2nd Toe - 3rd Toe - 4th Toe - 5th Other

  • Back- Lower
  • Back- Upper
  • Head
  • Ear - Left
  • Ear - Right
  • Eye - Left
  • Eye - Right
  • Nose
  • Mouth
  • Face
  • Neck
  • Chest
  • Ribs
  • Abdomen
  • Groin
  • Internal
  • Shoulder - Left
  • Shoulder - Right
  • Upper Arm - Left
  • Upper Arm - Right
  • Elbow - Left
  • Elbow - Right
  • Lower Arm - Left
  • Lower Arm - Right
  • Wrist - Left
  • Wrist - Right
  • Hand - Left
  • Hand - Right
  • Finger - 1st
  • Finger - 2nd
  • Finger - 3rd
  • Finger - 4th
  • Finger - 5th
  • Buttocks/Pelvis
  • Upper Leg - Left
  • Upper Leg - Right
  • Knee - Left
  • Knee - Right
  • Lower Leg - Left
  • Lower Leg - Right
  • Ankle - Left
  • Ankle - Right
  • Foot - Left
  • Foot - Right
  • Toe - 1st
  • Toe - 2nd
  • Toe - 3rd
  • Toe - 4th
  • Toe - 5th
  • Other

• Please specify Other Body Part

3. Medical Information

• Offsite Medical Treatment Required

  Yes

  No

• Offsite Emergency Medical Treatment Required

  Yes

  No

• Employee Transported By

• Emergency Contact Notified

  Yes

  No

• Treating Clinic/Hospital

• Treating Doctor

4. Cause Factors & Corrective Actions

• Note: After listing all surface causes, complete a 5 Whys Worksheet for each surface cause

Part A: Surface Causes

• Hazardous conditions or unsafe behaviors - process, equipment, environmental/work area, people

Part B: Root Cause(s) - 5 Whys Worksheet

• Attach worksheet when completed - Enter solution(s) in Corrective Actions below.

  Media

Part C: Corrective Actions: Refer to the solutions found in the 5 Whys Worksheet

• Tap "+"

Immediate Corrective Action - required prior to equipment "Return to Service"

• Action Item

• Person Responsible

• Target Date

  Date

• Completion Date

  Date

• CI Card Number

Short Term Corrective Action

• Action Item

• Person Responsible

• Target Date

  Date

• Completion Date

  Date

• CI Card Number

Long Term Corrective Action

• Action Item

• Person Responsible

• Target Date

  Date

• Completion Date

  Date

• CI Card Number

System Improvement

• Action Item

• Person Responsible

• Target Date

  Date

• Completion Date

  Date

• CI Card Number

• Investigation Completed By

• Name(s)

• Date

  Date

• Attachments

  Select Photos Sketches Interview Notes Diagrams 5 Why Other

  • Photos
  • Sketches
  • Interview Notes
  • Diagrams
  • 5 Why
  • Other

• Describe

5. Review & Follow-Up Actions by Manager

• Manager is responsible for ensuring all Action Items in Section 4C above are completed. When all action items are completed, please return this form and all other attachments to the Safety Department

• Reviewed By

• Title

• Date Incident Investigation Report Closed

  Date