Incident Investigation Report
Instructions: : Complete this form as soon as possible after an incident that results in serious injury or illness.(Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)
This is a report of a
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DEATH
LOST TIME
DR. VISIT ONLY
FIRST AID ONLY
NEAR MISS
Date
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-
Month
-
Day
Year
Date
This report is made by:
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Employee
Supervisor
Team
Other
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STEP 1: Injured employee (complete this part for each injured employee)
If there are multiple employee's injured please fill out a separate form per employee.
Name
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First Name
Last Name
Sex:
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Male
Female
Age:
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Department:
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Job title at time of incident:
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This employee works:
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Regular full time
Regular part time
Seasonal
Temporary
Months with this employer:
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Months with doing this job:
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Nature of injury: (most serious one)
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Abrasion, scrapes
Amputation
Broken bone
Bruise
Burn (heat)
Burn (chemical)
Concussion (to the head)
Crushing Injury
Cut, laceration, puncture
Hernia
Illness
Sprain, strain
Damage to a body system:
Other
Click on the pin below to shade part of body affected.
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STEP 2: Describe the incident
Exact location of the incident:
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Exact time:
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Hour Minutes
AM
PM
AM/PM Option
If employee went to the doctor, please state the doctor's name below:
Doctor's Name, Date Seen and Time Seen
Hospital/ Clinic:
Phone Number:
Doctor or Clinic's Phone Number
Doctor's Email Address:
example@example.com
Drug Tested:
YES
NO
If no, explain:
Recommended preventative action to take in the future to prevent reoccurrence.
What part of employee's workday?
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Entering or leaving work
During normal work activities
During meal period
During break
Working overtime
Other
Name of witnesses (if any):
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If there were no witnesses please type "none" in the box above
ATTACHMENTS:
If you do not currently have the following three items, please skip them and send these attachments via email to rhonda.g@jeffmartinauctioneers.com ASAP.
#1 STATEMENTS:
Written Witness Statement:
Written Employee Statement:
Written Supervisor Statement:
#2 Photographs:
#3 Maps/Drawings:
What personal protective equipment was being used (if any)?
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If there were no personal protective equipment used please type "none" in the box above
Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details.
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STEP 3: Why did the incident happen?
Unsafe workplace conditions: (check all that apply)
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Inadequate guard
Unguarded hazard
Safety device is defective
Tool or equipment defective
Workstation layout is hazardous
Unsafe lighting
Unsafe ventilation
Lack of needed personal protective equipment
Lack of appropriate equipment / tools
Unsafe clothing
No training or insufficient training
Other
Unsafe acts by people: (Check all that apply)
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Operating without permission
Operating at unsafe speed
Servicing equipment that has power to it
Making a safety device inoperative
Using defective equipment
Using equipment in an unapproved way
Unsafe lifting
Taking an unsafe position or posture
Distraction, teasing, horseplay
Failure to wear personal protective equipment
Failure to use the available equipment / tools
Other
Why did the unsafe conditions exist?
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Why did the unsafe acts occur?
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Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that may have encouraged the unsafe conditions or acts?
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YES
NO
If yes, describe:
Were the unsafe acts or conditions reported prior to the incident?
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YES
NO
Have there been similar incidents or near misses prior to this one?
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YES
NO
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STEP 4: How can future incidents be prevented?
What changes do you suggest to prevent this incident/near miss from happening again?
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Stop this activity
Guard the hazard
Train the employee(s)
Train the supervisor(s)
Redesign task steps
Redesign work station
Write a new policy/rule
Enforce existing policy
Routinely inspect for the hazard
Personal Protective Equipment
Other
What should be (or has been) done to carry out the suggestion(s) checked above?
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STEP 5: Who completed and reviewed this form?
Written by:
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First Name
Last Name
Signature:
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Department:
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Title:
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Email
example@example.com
Date
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Month
-
Day
Year
Date
Names of investigation team members:
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Injured Employee Name:
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First Name
Last Name
Date
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Month
-
Day
Year
Date
Employee Signature
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The following are for the HR Director to sign for review:
Please skip this section if you are not the HR Director
Reviewed By:
First Name
Last Name
Title:
Date
-
Month
-
Day
Year
Date
Reviewers Signature:
Preview PDF
Submit
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