Workplace Injury - Supervisor's Incident Investigation

• Policy# - 34WEID5939

• Date of Injury

  Date

• Date Employer was notified of injury by Injured Employee

  Date

• Prepared by

• Preparer Phone #

• Site Address

• Site Telephone #

• Location
  Address

Injured Employee Information

• Full Name of Injured Employee

• Birth Date of Injured Employee

  Date

• Home Address of Injured Employee

• Phone Number of Injured Employee

• Employment Status of Injured Employee

  Full Time

  Part Time

• Job Title of Injured Employee

• Date of Hire for Injured Employee

  Date

• How long in current position (Years and Months) for Injured Employee

• Hours Worked per Day

• Days Worked per Week

• Weeks Worked in Last 12 Months

• Last Day Worked

  Date

• Date Returned to Work/Expected Return to Work Date

  Date

Description of Incident

• Where on site did the injury occur?

  Select Prep Area Back Room Wash Tunnel Tunnel Exit Vacuum Area/Parking Lot Detail Bay Full Service Bay Office/Lobby Greeter Area/Queue XPT/Pay Station Other

  • Prep Area
  • Back Room
  • Wash Tunnel
  • Tunnel Exit
  • Vacuum Area/Parking Lot
  • Detail Bay
  • Full Service Bay
  • Office/Lobby
  • Greeter Area/Queue
  • XPT/Pay Station
  • Other

• Please list where on site the injury occurred.

• Please take pictures of the area where the injury occurred, and of any hazards, equipment, vehicles, tools, products or any other conditions contributing to the incident.

  Media

• Please provide a description of the incident:

• Were authorities contacted?

  Yes

  No

• Which authorities were contacted?

  Select Police Fire Ambulance

  • Police
  • Fire
  • Ambulance

• Was a report # given?

  Yes

  No

• List the report #

• Description of any injuries incurred (part of body, type of injury)

• Treatment Provided

  No Medical Treatment

  Minor on-site remedies

  Minor Clinic or Hospital

  Emergency Evaluation

  In-Patient Hospitalization

• Name, Address and Phone # of Treating Hospital/Clinc

• Name, Address and Phone # of Treating Hospital/Clinc

• Name, Address and Phone # of Treating Hospital/Clinc

• Were there any witnesses to the incident?

  Yes

  No

• Please have all witnesses fill out the Witness Statement template

• Name(s) and Phone Number(s) of all witnesses to the incident

Root Cause Analysis

• Which have been determined to be the root cause(s) of the incident?

  Select Unsafe Conditions (i.e. - Trip Hazards, Machine Guarding, Electrical Hazards, etc.) Unsafe Behaviors (Improper Positioning, Proper Resources not used or not available, Eyes not on Task, No PPE) Equipment Malfunction Other

  • Unsafe Conditions (i.e. - Trip Hazards, Machine Guarding, Electrical Hazards, etc.)
  • Unsafe Behaviors (Improper Positioning, Proper Resources not used or not available, Eyes not on Task, No PPE)
  • Equipment Malfunction
  • Other

• Please describe the unsafe conditions that led to the injury

• Please describe the unsafe behaviors that led to the injury

• Please describe the equipment malfunction that led to the injury

• Please describe any other major contributors to the injury

Corrective Action

• Please describe what safety-related or operational improvements will be implemented in order to prevent this incident from happening again, and describe why they will be effective.

• Please create an action item for each corrective action described above, and assign it to the appropriate responsible party (i.e. - SM, DM, RM, RDO, Maintenance, EHS, HR, RVP).

OSHA Recordability of Incident

• Determine whether this injury is recordable under OSHA Standards

• Was the injury work-related (sustained at work, or while performing duties or tasks for the employer)?

  Yes

  No

• Is the injury a new case, or a significant aggravation of an existing injury?

  Yes

  No

• Which of the following did the injury result in (Select all that apply):

  Select Death Loss of Consciousness Days Away From Work Restricted or "Light" Duty Medical Treatment Beyond First Aid (i.e. stitches, splints, casts, prescription medication, surgery, therapy) Chronic Illness Broken Bones Needle Stick/Sharps Injuries Hearing Loss None of the Above

  • Death
  • Loss of Consciousness
  • Days Away From Work
  • Restricted or "Light" Duty
  • Medical Treatment Beyond First Aid (i.e. stitches, splints, casts, prescription medication, surgery, therapy)
  • Chronic Illness
  • Broken Bones
  • Needle Stick/Sharps Injuries
  • Hearing Loss
  • None of the Above

• This injury is OSHA Recordable and should be added to your OSHA 300 Log

• This injury is OSHA Recordable and should be added to your OSHA 300 Log

• This injury is OSHA Recordable and should be added to your OSHA 300 Log

• This injury is OSHA Recordable and should be added to your OSHA 300 Log

• This injury is OSHA Recordable and should be added to your OSHA 300 Log

• This injury is OSHA Recordable and should be added to your OSHA 300 Log

• This injury is OSHA Recordable and should be added to your OSHA 300 Log

• This injury is OSHA Recordable and should be added to your OSHA 300 Log

• This injury is OSHA Recordable and should be added to your OSHA 300 Log

• This injury is NOT OSHA Recordable.

• This injury is NOT OSHA Recordable

• This injury is NOT OSHA Recordable