Information
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Prepared by
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Conducted on
Site details
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Location of Incident
- NAVSTA 32
- NASSCO
- BAE
- CMSD
- NASNI
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Site that employee was working at;
Accident/Incident Details
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Date and time of injury;
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Employee Name
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Job Title:
- Laborer
- Painter
- Superintendent
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Nature of Incident or Injury
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Describe who, what, when,where, why and how injury occurred:
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Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)
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Possible Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilise safety equipment)
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What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)
Supervision details
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Was Risk Assessment completed before work began:
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Facility Safety Office Informed?
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Date and Time when the employer was notified:
Injured Party statement
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Name & Signature of the injured party
Witness statements
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Witnesses 1
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Name and signature of the witness 1
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Witnesses 2
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Name and signature of the witness 2
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Witnesses 3
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Name and signature of the witness 3
Injury Details if Applicable
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Where was the Medical treatment first provided?
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Provider Doctor Details
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Part of Body injured:
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Image of injury
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Will the employee have any restrictions:
Action: Short Term
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What was the immediate action taken to correct the issue (how was this done):
Action: Long Term
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What is the long term action needed to correct the issue:
Additional Information
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Lessons Learned:
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Please provide all attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.
Person Completing Form (please sign below)
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Is the above report a true reflection of the Accident / Incident
Supervisor in Charge (please sign below)
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Is the above report a true reflection of the Accident / Incident
Injured Party witnessing the completion of the forms agreement with the content and that it is a true reflection of the accident / Incident
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Is the above report a true reflection of the Accident / Incident
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Injured employee has received Workers Compensation DWC-1 report
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