Supervisor Incident Analysis

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Section A - Team Member / Basic Information

• Team Member Name (Last, First, MI)

• Incident Date and Time

  Date

• Date Incident Was Reported

  Date

• Employment Status

  Full Time

  Part Time

  On Call

• Regular Job

• Job Being Performed

• Department

• Experience with ACCB (in years)

• Experience with Department (in years)

• Experience with Job Task

  Frequent

  Infrequent

  None

• Length of Shift

  5

  6

  7

  8

  10

• Shift

  Day

  Swing

  Grave

• Time Since Start of Shift (in Hours and Minutes)

• Type of Shift

  Fixed

  Flexed

• Days Off

  Select Sunday Monday Tuesday Wednesday Thursday Friday Saturday

  • Sunday
  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday

Section B - Incident Information

• Incident Type

  01 - Injury

  02 - Illness

  03 - Fatality

  04 - Near Miss

  05 - Damage Only

• Exact Location of Incident (If off property, give address)

• Equipment or Materials Involved

• Contact Agent (The exact object/material that caused the injury)

• Describe the Incident

Section C - Incident Type

• Type of Incident

  Select 000 - Unknown 010 - Struck Against 020 - Struck By 030 - Fall - Elevation 040 - Fall - Same Level 050 - Caught In/Under/Between 060 - Bodily Reaction 070 - Overexertion - General 080 - Contact With 090 - Exposure 100 - Inhalation 110 - Ingestion 120 - Other

  • 000 - Unknown
  • 010 - Struck Against
  • 020 - Struck By
  • 030 - Fall - Elevation
  • 040 - Fall - Same Level
  • 050 - Caught In/Under/Between
  • 060 - Bodily Reaction
  • 070 - Overexertion - General
  • 080 - Contact With
  • 090 - Exposure
  • 100 - Inhalation
  • 110 - Ingestion
  • 120 - Other

• Please Describe

Section D - Incident Analysis System Challenges (Indicate all applicable challenges)

• Environment

  Select Physical Layout Hazardous Chemical Lighting Noise Weather Terrain Vibration Egronomics Leaks/Spills Temperature Housekeeping Biological Agent Other

  • Physical Layout
  • Hazardous Chemical
  • Lighting
  • Noise
  • Weather
  • Terrain
  • Vibration
  • Egronomics
  • Leaks/Spills
  • Temperature
  • Housekeeping
  • Biological Agent
  • Other

• Please Describe

• Team Member has (Select one)

  Lack of Knowledge

  Knew Process or Procedure

• Select One

  Never Trained

  Trained - Forgot or Inadequate Training

• Select One

  Hurrying or Rushing

  Anger or Frustration

  Tired or Fatigued

  Complacent, Distracted, or Day Dreaming

• Select all that apply

  Select Body or Body Part in the line of energy Loss of Balance Loss of Traction Loss of Grip Improper Body Position or Stress from Repeated Activity

  • Body or Body Part in the line of energy
  • Loss of Balance
  • Loss of Traction
  • Loss of Grip
  • Improper Body Position or Stress from Repeated Activity

• Equipment Conditions

  Select Selection Availability Maintenance Guarding Replacement Visual Warning(s) Other

  • Selection
  • Availability
  • Maintenance
  • Guarding
  • Replacement
  • Visual Warning(s)
  • Other

• Please Describe

• Management (What oversights were there by Management that could have led to this incident) Select all that apply.

  Select Policy Enforcement Hazard Recognition Accountability Knowledge/Training Coaching Task Process(s) Maintenance/Repairs Staffing/Shifts Physical Layout Equipment/Supplies Other

  • Policy Enforcement
  • Hazard Recognition
  • Accountability
  • Knowledge/Training
  • Coaching
  • Task Process(s)
  • Maintenance/Repairs
  • Staffing/Shifts
  • Physical Layout
  • Equipment/Supplies
  • Other

• Please Describe

Section E - Preventive Measuers

• What action has been taken or is planned to prevent recurrence? Select all that apply.

  Select Re-instruction/Retraining Training Coaching Development of Training Improve Task/Job Procedures Improve Housekeeping/Cleanup Job Hazard Analysis/Ergonomic Eval Needed Guard/Safety Device Personal Protective Equipment Tools/Equipment replaced/repaired/ordered Eliminate Congestion Improve Design/Construction Substitute Safer Materials/Supplies/Chemicals Improve Lighting Improve Ventilation Reduction in Noise/Vibration Enforce Procedures Other

  • Re-instruction/Retraining
  • Training
  • Coaching
  • Development of Training
  • Improve Task/Job Procedures
  • Improve Housekeeping/Cleanup
  • Job Hazard Analysis/Ergonomic Eval Needed
  • Guard/Safety Device
  • Personal Protective Equipment
  • Tools/Equipment replaced/repaired/ordered
  • Eliminate Congestion
  • Improve Design/Construction
  • Substitute Safer Materials/Supplies/Chemicals
  • Improve Lighting
  • Improve Ventilation
  • Reduction in Noise/Vibration
  • Enforce Procedures
  • Other

• Please Describe

• How will the above action(s) improve operations?

Section F - Signature and Review

• Note: I have reviewed this report I am confident that the incident was thoroughly analyzed and proper actions have been taken or are planned to be taken to prevent recurrence.

• Analysis By (Immediate Supervisor)

  Sign

• Team Member Involved (Review)

  Sign