Making Investgation form homework?

Use Separate Form for Each Person/Incident Incident/Accident Initial Report Form IC# ________________

1. Incident Specifics

3. Persons Involved/Affected

4. Interventions/Treatment

Was the activity covered by FMEA?

N/A Yes No

Where did the Incident Happen?

Type of Person Involved/Affected

None(0) First Aid(1)

Recordable Injury(2) Hospitalized(3)

Site/Bldg:

(check) Employee Contractor Visitor Other___________

Immediate Corrective Actions Taken

Dept:

5. Witnesses or Persons Present (if any)

Area:

If contractor, list name of company

Name:

When did the Incident Happen?

Date: / /

Time: : am/pm

Details of Person Involved/Affected

□ Male □ Female

When was this report submitted?

Name:

Date of Birth: / /

Date: / /

Time: : am/pm

Address:

Has the Policy Been Reviewed?

N/A Yes No

2. The Incident

□ Male □ Female

Description of event (facts only)

Date of Birth: / /

City:

Countermeasures/Recommendations:

Address:

State:

Zip:

City:

Phone: ( )

State:

Name:

Zip:

Address:

Phone: ( )

Follow up Required?

Yes No

Person Submitting Report

City:

Name:

State:

Date of Follow up: / /

Zip:

Person Responsible for Follow up:

Supervisor

Phone: ( )

Name:

Name:

7. Signatures

Completing and signing this form does not constitute an admission of liability of any kind, either by the person making the report or any other person.

Type of Incident (check all that apply)

Address:

□ Lifting/handling

□ Ill health

□ Fall from height/stairs

□ Slip/trip/fall

□ Contact with electricity

□ Hot/cold contact

□ Dangerous occurrence

□ Cut with sharp object

□ Near miss incident

□ Property loss/damage

□ Fire (fire incident form required)

□ Threatening behavior

□ Verbal Abuse

□ Person to person assault

□ Equipment failure/misuse

□ Struck by/against something

□ Contact/exposure to equipment/machinery

□ Contact/exposure to harmful substance

□ Fatality

□ Other (please specify) ____________________

_______________________________________

___________________________________________

Impact on Individual/Severity

Person Completing this Form

None(0) Minor(1)

Moderate(2) Major(3)

City:

Signature:

State:

Print Name:

Was There an Injury?

Zip:

Date:

Which Side? Left Right

Phone: ( )

Job Title:

Type of injury (Check all that apply)

6. Investigation

Phone: ( )

□ Abrasion

□ Fracture/dislocation

□ Amputation

□ Laceration

□ Bruise

□ Pain

□ Burn/scald

□ Puncture

□ Crush/internal injury

□ Sprain/strain

□ Distress

□ Swelling

□ Other (please specify) ______________________

__________________________________________

□ Body Part injured:

Was the location of the Person/Equipment Authorized?

N/A Yes No

Manager/Supervisor

Signature:

Was the Activity of the Person Authorized?

N/A Yes No

Print Name:

Date:

Were Safe Work Practices Being Used?

N/A Yes No

Title:

Phone: ( )

Contributory Factors (check one)

Environment Equipment/Materials Procedure Human Factors

Other

For Safety Use Only

Received By:

Date:

Evidence Form

IC#

Who Collected It?

Scene Sketch

(Use additional form if necessary)

Date Collected:

Signature:

Time Collected:

Print:

Storage Location:

Description of Evidence

Photo Attachments

(use additional form if necessary)

Scene Sketch Remarks

Date:

Preparer’s Signature:

Evidence Chain of Custody Form

IC#

Submitter

Receiver

Name:

Name:

Signature:

Signature:

Date: / /

Time: : am/pm

Date: / /

Time: : am/pm

Submitter

Receiver

Name:

Name:

Signature:

Signature:

Date: / /

Time: : am/pm

Date: / /

Time: : am/pm

Submitter

Receiver

Name:

Name:

Signature:

Signature:

Date: / /

Time: : am/pm

Date: / /

Time: : am/pm

Incident Summary and Countermeasures

Facts of the Incident

Identified Causes

Immediate

Root

Countermeasures Implemented

Immediate

Root

Work Area

Job Hazard Analysis Form

Site

Date

Activity or Task:

Completed By:

Work Steps and Tasks

Describe the tasks / steps involved in the work – in order

Hazards Identified for each Task / Step

Risk Level

Use Hazard Analysis Matrix Calculator

Control / Safe Work Procedures for each Task / Step

Controls to be implemented (consider the hierarchy of hazard controls)

Hazards Checklist

· Can someone be struck or contacted by anything while doing this job?

· Can someone slip, trip or fall?

· Can someone fall into anything?

· Can someone strike against or make contact with any physical hazards?

· Can someone strain or overexert?

· Can damage to equipment occur?

· Can someone be exposed to any hazardous conditions?

· Can someone be caught in anything?

· Can someone injure someone else?

Safety Officers/Mangers/Supervisors Comments

Employee Signature:

HAZARD ANALYSIS MATRIX CALCULATOR

Consequences

Probability or Impact Definitions:

1. Unlikely

2. Possible

3. Likely

4. Almost Certain

Outcome not expected to occur

Outcome might occur at sometime

Outcome could occur occasionally

Outcome will occur often

4.Critical

Managing People: Significant restrictions on resourcing key processes throughout the organization; operational demise; multiple deaths, Regulatory intervention.

Product and service delivery: System-wide cessation of multiple processes; greater than one month operational delay.

Performance/Financial: Impact on >/= 25% of budget. Major program objectives not achieved.

Information Management/Administrative Systems: System-wide loss of services, programs or data.

Infrastructure/Asset Management: Long term and possible permanent loss of property or assets.

Managing the environment (internal/external): Sustained adverse publicity. Extreme /public outrage, permanent community/ environmental impact.

Medium Ongoing safety management/ monitoring of specified improvement activities

High Review by Senior Executive &/or Senior Safety Officer

Extreme Immediate action of Senior Executive, Senior Safety Officer / notification of Chief Executive Officer

Extreme Immediate action of Senior Executive, Senior Safety Officer / notification of Chief Executive Officer

3 Major

Managing People: Noticeable restrictions on resourcing some processes; loss of life or permanent injury: Regulatory investigation.

Product and service delivery: Cessation of some processes; up to one month operational delay.

Performance/Financial: Impact on </= 10%; Major performance outputs not achieved.

Information Management/Administrative Systems: Loss or restrictions to key services, programs or large loss or theft of data.

Infrastructure/Asset Management: Sustained damage to property or assets lasting many months

Managing the environment (internal/external): Significant public sensitivity, long term detrimental impact on community & the environment & stakeholder relationships.

Medium Ongoing safety management/ monitoring of specified safety improvement activities

High Review by Senior Executive &/or Senior Safety Officer

High Review by Senior Executive &/or Senior Safety Officer

Extreme Immediate action of Senior Executive, Senior Safety Officer / notification of Chief Executive Officer

2 Moderate

Managing People: Localized restrictions on resourcing processes; serious injury requiring hospitalization or medical treatment; minor code of conduct breach.

Product and service delivery: Disruption to a number of processes; up to one week operational delay.

Performance/Financial: Impact on </= 5% of budget; Some key deliverables not achieved.

Information Management/Administrative Systems: Restrictions to services, programs & loss or theft of some data.

Infrastructure/Asset Management: Significant but temporary damage to property or assets.

Managing the environment (internal/external): Significant adverse publicity state-wide, adverse community or environmental impact to notable levels.

Low Managed at operational level using safety procedures

Medium Ongoing safety management/ monitoring of specified safety improvement activities

High Review by Senior Executive &/or Senior Safety Officer

High Review by Senior Executive &/or Senior Safety Officer

1 Minor

Managing People: Minimal effect on resourcing processes; First-aid injury-no lost time; local workforce management issue.

Product and service delivery: Minimal disruption to processes; up to one day operational delay.

Performance/Financial: Impact on </= 2% of budget; Loss of less than (predetermined budgeted amount); Minimal impact on output.

Information Management/Administrative Systems: Minor effect on services, programs.

Infrastructure/Asset Management: Slight/ temporary damage to property or assets.

Managing the environment (internal/external): Short term adverse community impact; Short term local environmental issue.

Low Managed at operational level using safety procedures

Low Managed at operational level using safety procedures

Medium Ongoing safety management/ monitoring of specified safety improvement activities

Medium Ongoing safety management/ monitoring of specified safety improvement activities

Incident Cost Calculator Sheet

Incident Costs

Time

Rate

Costs

Time to provide first aid

Time for transportation to hospital/clinic/home

Lost productivity of all affected workers

Time to make area safe

Cost of first aid supplies and equipment used

Cost of ambulance or transportation

Other Costs:

Investigation Costs

Time

Rate

Costs

Time to Investigate accident

Time spent to complete an accident investigation report

Time to complete related paperwork for your company (e.g. company records or accident book, payroll records, company report forms, etc.

Time to complete related paperwork

For serious accidents, time taken to report incident to OSHA and meet with regulators which may include time to assist with an investigation

Follow-up meetings to discuss accident

Other costs:

Damage Costs

Time

Rate

Costs

Time to assess damage

Time to repair or replace equipment

Time to coordinate repair work

Clean up time (includes coordination)

Cost of outside contractors and materials for clean-up

Costs to dispose of damaged equipment

Cost of replacement parts, equipment, or lost product (e.g. robbery, spoilage, miscellaneous damage, loss of truck load)

Other costs:

Replacement Costs

Time

Rate

Cost

Time to hire or relocate replacement worker

Relocation or rescheduling of another worker

Trainer time for new or relocated worker

Trainee time for new or relocated worker

Cost to hire a replacement worker

Other costs:

Productivity Costs

Time

Rate

Costs

Lost productivity (work time) due to disruption (delays, waiting to resume, etc.)

Time spent managing the injury claim

Reduced productivity of injured worker after they return to work

Other costs:

Summary of Accident Costs

Costs

Incident Costs

Investigation Costs

Damage Costs

Replacement Costs

Productivity Costs

Total

Total cost of the accident:

Average profit margin:

Average sales or revenue per day:

Recovery Costs

3% Margin

5% Margin

7% Margin

Gross sales required to recover accident cost

$

$

$

Number of working days to recover accident cost

$

$

$

Executive Summary

(include analysis of countermeasures, progress report, guidance, and disposition of case)

Disposition:

Signature:

Date: / /