YYK Accident Report

• Prepared by

  Temo Ochoa

  Carlos Sosa

  Ron Pivaro

• Conducted on

  Date

Site details

• Location of Incident

  Select NAVSTA 32 NASSCO BAE CMSD NASNI

  • NAVSTA 32
  • NASSCO
  • BAE
  • CMSD
  • NASNI

• Site that employee was working at;

Accident/Incident Details

• Date and time of injury;

  Date

• Employee Name

• Job Title:

  Select Laborer Painter Superintendent

  • Laborer
  • Painter
  • Superintendent

• Nature of Incident or Injury

• Describe who, what, when,where, why and how injury occurred:

• Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)

• Possible Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilise safety equipment)

• 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

• Was Risk Assessment completed before work began:

  Yes

  No

  N/A

• Facility Safety Office Informed?

  Yes

  No

  N/A

• Date and Time when the employer was notified:

  Date

Injured Party statement

• Name & Signature of the injured party

  Sign

Witness statements

• Witnesses 1

• Name and signature of the witness 1

  Sign

• Witnesses 2

• Name and signature of the witness 2

  Sign

• Witnesses 3

• Name and signature of the witness 3

  Sign

Injury Details if Applicable

• Where was the Medical treatment first provided?

  South Coast Medical Center

  Emergency Room

• Provider Doctor Details

• Part of Body injured:

• Image of injury

  Media

• Will the employee have any restrictions:

  Lost Time

  No Restriction

  Return to Work Next Day

Action: Short Term

• What was the immediate action taken to correct the issue (how was this done):

Action: Long Term

• What is the long term action needed to correct the issue:

Additional Information

• Lessons Learned:

• Please provide all attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.

  Yes

  No

  N/A

Person Completing Form (please sign below)

• Is the above report a true reflection of the Accident / Incident

  Sign

Supervisor in Charge (please sign below)

• Is the above report a true reflection of the Accident / Incident

  Sign

Injured Party witnessing the completion of the forms agreement with the content and that it is a true reflection of the accident / Incident

• Is the above report a true reflection of the Accident / Incident

  Sign

• Injured employee has received Workers Compensation DWC-1 report

  Yes

  No

  N/A

• Add signature

  Sign