TI Grocery Accident Investigation v. 1

• ACCIDENT INVESTIGATION PROCEDURE
  
  The following steps should be taken following report of a work-related illness accident resulting in property loss or injury/illness requiring medical attention. The investigation procedure outlined must be completed by the immediate supervisor within 24 hours of notification of the incident.
  
  1. Immediately secure proper medical treatment for injured.
  2. Investigate/report accident:
  A. Do not disturb accident site until adequate review has been completed.
  B. Talk to eyewitnesses; take notes.
  C. Carefully recreate accident, and take photographs as appropriate.
  D. Consider all aspects of accident cause; who, what, when, where, how, why.
  E. Complete the Employee Injury Report. Take note that the purpose of accident investigation is prevention of future accidents, not fixing blame.
  

• Prepared By

• Conducted on

  Date

• Store Location

  Select 3460 N. Broadway 75 W. Elm Street 1639 N. Wells Street 1526 E. 55th Street 911 Ridge Road 2121 N. Clybourn 680 N. Lake Shore Drive

  • 3460 N. Broadway
  • 75 W. Elm Street
  • 1639 N. Wells Street
  • 1526 E. 55th Street
  • 911 Ridge Road
  • 2121 N. Clybourn
  • 680 N. Lake Shore Drive

Type of Injury

• Who was injured?

  Employee

  Customer

Take Photos

• Photo of injured part of body (required)

  Media

• Photo of the cause of the injury (injury)

  Media

• Photo of surroundings (required)

  Media

• Additional photo (optional)

  Media

Employee Information

• EMPLOYEE NAME

• EMPLOYEE'S DEPARTMENT

  Select Produce Cooler Deli Prep Liquor Storage Meat Processing Chicken Processing Meat Storage Chicken Storage Parking Lot Other Back of House

  • Produce Cooler
  • Deli Prep
  • Liquor Storage
  • Meat Processing
  • Chicken Processing
  • Meat Storage
  • Chicken Storage
  • Parking Lot
  • Other Back of House

• EMPLOYEE's JOB TITLE

  Select Manager Supervisor Cook Cashier Admin Stocker Employee

  • Manager
  • Supervisor
  • Cook
  • Cashier
  • Admin
  • Stocker
  • Employee

• Shift Number at time of accident

Injury Information

• DATE & TIME OF INCIDENT (Not this report)

  Date

• INCIDENT LOCATION

  Select Produce Cooler Deli Prep Liquor Storage Meat Processing Chicken Processing Meat Storage Chicken Storage Parking Lot Other Back of House

  • Produce Cooler
  • Deli Prep
  • Liquor Storage
  • Meat Processing
  • Chicken Processing
  • Meat Storage
  • Chicken Storage
  • Parking Lot
  • Other Back of House

• INJURY ILLNESS

  Select Abrasion Amputation Bruise Burn Crushing Cumulative trauma Cut, puncture Skin related Fracture Hearing Hernia Shock, electrical Sprain, strain Other

  • Abrasion
  • Amputation
  • Bruise
  • Burn
  • Crushing
  • Cumulative trauma
  • Cut, puncture
  • Skin related
  • Fracture
  • Hearing
  • Hernia
  • Shock, electrical
  • Sprain, strain
  • Other

• BODY PART INJURED

  Select Abdomen Arm Back Chest Ear Eye Finger Food Hand Head Internal Leg Neck Nose Mouth Shoulder Toe Wrist

  • Abdomen
  • Arm
  • Back
  • Chest
  • Ear
  • Eye
  • Finger
  • Food
  • Hand
  • Head
  • Internal
  • Leg
  • Neck
  • Nose
  • Mouth
  • Shoulder
  • Toe
  • Wrist

• SOURCE OF INJURY

  Select Bodily motion Building Chemical Electrical Machine Material handling Motor vehicle Stairs, ladder Tool Walking surface Working surface

  • Bodily motion
  • Building
  • Chemical
  • Electrical
  • Machine
  • Material handling
  • Motor vehicle
  • Stairs, ladder
  • Tool
  • Walking surface
  • Working surface

• ACCIDENT TYPE

  Select Absorption, inhalation, Ingestion of toxins Bodily reaction Caught in, under, between Contact w/ electrical Contact w/ hot surface-item Fall from elevation Fall from same level Motor vehicle Overexertion Rubbed, abraded Struck against Struck by

  • Absorption, inhalation, Ingestion of toxins
  • Bodily reaction
  • Caught in, under, between
  • Contact w/ electrical
  • Contact w/ hot surface-item
  • Fall from elevation
  • Fall from same level
  • Motor vehicle
  • Overexertion
  • Rubbed, abraded
  • Struck against
  • Struck by

• INCIDENT CAUGHT ON VIDEO?

  YES

  NO

Cause of Injury (Check All That Apply)

• Cause of Injury

  Select Bypassing safety devices Not paying attention Failure to secure or warn Failure to use protective equipment Failure to wear protective attire Horseplay Improper use of body Improper use of equipment, tools Inadequate maintenance Incorrect lifting, carrying Operating without authority Poor housekeeping Unstable loading, stacking Using defective equipment, tools Working on live equipment

  • Bypassing safety devices
  • Not paying attention
  • Failure to secure or warn
  • Failure to use protective equipment
  • Failure to wear protective attire
  • Horseplay
  • Improper use of body
  • Improper use of equipment, tools
  • Inadequate maintenance
  • Incorrect lifting, carrying
  • Operating without authority
  • Poor housekeeping
  • Unstable loading, stacking
  • Using defective equipment, tools
  • Working on live equipment

Employee's Description of Accident

Department Manager/Supervisor Description of Accident

Witnesses

• Are there any witnesses?

  Yes

  No

  N/A

• Employee Name

• Witness Description

Management Action

• Select Develop, revise written process/SOP Initiate, revise, enforce rules Improve emergency/medical system Improve housekeeping, maintenance Improve job orientation, training Install, replace, adjust guards Institute job hazard/ergonomics analysis Modify, replace, tools, equipment Provide inspections, observations Provide proper employee placement Provide/monitor protective equipment Provide special communication Review via task force, committee Revise equipment layout

  • Develop, revise written process/SOP
  • Initiate, revise, enforce rules
  • Improve emergency/medical system
  • Improve housekeeping, maintenance
  • Improve job orientation, training
  • Install, replace, adjust guards
  • Institute job hazard/ergonomics analysis
  • Modify, replace, tools, equipment
  • Provide inspections, observations
  • Provide proper employee placement
  • Provide/monitor protective equipment
  • Provide special communication
  • Review via task force, committee
  • Revise equipment layout

Customer Injury

• DATE & TIME OF INCIDENT

  Date

• INCIDENT CAUGHT ON VIDEO?

  YES

  NO

• INCIDENT LOCATION

  Select Produce Cooler Deli Prep Liquor Storage Meat Processing Chicken Processing Meat Storage Chicken Storage Parking Lot Other Back of House

  • Produce Cooler
  • Deli Prep
  • Liquor Storage
  • Meat Processing
  • Chicken Processing
  • Meat Storage
  • Chicken Storage
  • Parking Lot
  • Other Back of House

• AISLE NUMBER

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15

• BODY PART INJURED

  Select Abdomen Arm Back Chest Ear Eye Finger Food Hand Head Internal Leg Neck Nose Mouth Shoulder Toe Wrist

  • Abdomen
  • Arm
  • Back
  • Chest
  • Ear
  • Eye
  • Finger
  • Food
  • Hand
  • Head
  • Internal
  • Leg
  • Neck
  • Nose
  • Mouth
  • Shoulder
  • Toe
  • Wrist

• ALLEGED INJURY TYPE?

  Slip

  Trip

  Fall

  Struck By

• ALLEGED INJURY CAUSE?

  Select Water on floor Other liquid on floor Food debris on floor Fixture Own feet Other person Floor mat

  • Water on floor
  • Other liquid on floor
  • Food debris on floor
  • Fixture
  • Own feet
  • Other person
  • Floor mat

PHOTOGRAPHS

• PHOTO OF BOTTOM OF CUSTOMER SHOES

  Media

• PHOTO OF FLOOR WITH HAZARD in PICTURE (CLOSE UP)

  Media

• PHOTO OF FLOOR WITH HAZARD in PICTURE (WIDE ANGLE)

  Media

• PHOTO OF INJURED PERSON'S PART OF BODY

  Media

SEQUENCE OF EVENTS

• SEQUENCE OF EVENTS (DESCRIBED BY INJURED PERSON)

• DRAW INCIDENT (If Applicable)

  Drawing

• SIGNATURE OF INJURED PERSON

  Sign

WITNESSES

• ARE THERE ANY WITNESSES?

  YES

  NO

• Witess Name

• Witness Phone Number

• Witness Description of Accident