University of Minnesota Accident Investigation (Office of Occup. Health and Safety)

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

GENERAL INFORMATION ABOUT THE INVESTIGATION

• Date investigation opened

  Date

• Investigated by:
  (includes other employers)

investigator

• Name

• Employer and department

• Email

• Phone

GENERAL INFORMATION ABOUT THE INCIDENT

• Date and time of incident (if known)

  Date

• Location (Be as specific as possible. Include address, building name, room number, etc. as appropriate)

• Briefly describe the location (i.e. "classroom", "lab", "outdoor constuction", etc)

• Briefly describe the incident.

• Did the incident result in any of the following? (check all that apply)

  Select Fatality Serious/permanent injury or illness Non-Serious injury or illness Property damage Near miss

  • Fatality
  • Serious/permanent injury or illness
  • Non-Serious injury or illness
  • Property damage
  • Near miss

VICTIM(S)

• Were there any victims in the incident?
Victim

• Name

• Date of Birth

  Date

• Employer/Department or Job Title

• Phone

• E-mail

• Was this person physically injured?

• If this person is employed by the university, has a first report of injury been submitted to the office of risk management (ORM)?

  Yes. Electronically

  Yes. Hardcopy

  No

  Not applicable

• Describe the injuries. Be as specific as possible.

• Did this person receive medical treatment beyond first aid?

• Hospital/Clinic/Physician

WITNESS(ES)

• Were there any winesses to the incident?
Victim

• Name

• Employer/Department or Job Title

• Phone

• E-mail

• Does this witnesses account of the incident support the victim's account?

  Yes

  No

  Partially

• Explain.

VICTIM AND WITNESS STATEMENTS

Victim or Witness

• Be sure to identify the victim or witness to whom this statement belongs!!!

THE WORK ENVIRONMENT

• Was the work environment a factor in this incident?

• Explain:

• Provide a diagram of the work environment(as appropriate)

  Drawing

• Provide another diagram if needed.

  Drawing

MACHINES, EQUIPMENT, VEHICLES

• Were any machines, equipment, or vehicles involved in the incident?

• Please provide information on each machine, piece of equipment, or vehicle

machine, equipment, vehicle

• Short description (i.e. "2012 Ford Explorer", "6 foot step ladder", "radial arm saw")

• Manufacturer

• Model

• Year/date of manufacture if known

• Serial number/Vehicle Identification Number (VIN)/Other unique identifier

• Who owns this machine/equipment/vehicle?

• Who was operating/in control of the machine, equipment, or vehicle at the time of the incident?

• What was the general condition of the machine, equipment, or vehicle at the time of the incident?

• Describe any defects, violations, deficiencies or hazards noted in the machine, equipment, or vehicle that might have contributed to the incident?

• Describe any relevant modifications.

• Does this machine, equipment, or vehicle have any known history of defects or other accidents?

• Has this machine, equipment, or vehicle ever been inspected?

  Yes

  No

• by whom?

• When was the most recent inspection?

  Date

• What were the findings?

• Are there records of this inspection? Where are they? Who has them?

PERSONAL PROTECTIVE EQUIPMENT (PPE)

• Is PPE, or lack thereof, a factor in this incident?

• Is there any req. for PPE, such an OSHA regulation, a workplace rule, an SOP, a sign/placard?

  Yes

  No

• Describe the rule/guideline.

• Was the employee in compliance with those rules? Why/Why not? What PPE was in use? Include make, model, size, style. in the case of hearing protection , include NRR. In the case of respiratory protection, include cartridge and filter information, as well as recent change out details.

• Had rules regarding PPE been communicated to employee at time of hire and at leadt annually thereafter?

  Yes

  No

• describe. include dates. was training documented?

UNSAFE/AT-RISK BEHAVIORS AND ACTIONS

• Was an unsafe/at-risk behavior or action a factor in the incident?

• Describe:

• Is there a specific formal safety rule or OSHA regulation that was violated?

  Yes

  No

• Describe:

• Was this rule/regulation communicated to the employee? how? when? was this documented?

• Has disciplinary action been taken? Describe.

EMPLOYER'S SAFETY PROGRAMS, PROCEDURES, AND TRAINING

SUBROGATION

• Are there opportunities for subrogation in this case?
Subrogation opportunity

• Name/Company

• Reason/justification

• Has all physical evidence been secured, photographed, or otherwise preserved?