Making Investgation form homework?

S.O.____________________ Investigation Report I.C. #__________________

Open / Closed

Date of Incident: ___/___/___ Date of Report: ___/___/___ Dept: _________________

Time of Incident: _________ Time of Report: __________ Shift:_________________

Location or Machine #:_____________

Environmental Conditions:(circle) Indoor or Outdoor Temp. _____ WBGT. ____ Wind Speed____

General Description:(circle) rain snow ice icy wet dry cloudy sunny windy fog dusty

Lighting: (circle) dawn daylight dusk dark- outside lighting on indoor plant lighting on

dark- outside lighting off indoor plant lighting off

dark- outside lighting inop indoor plant lighting inop

First Aid at scene: yes no First Aid provider:________________________

Injured removed to:_______________________________________________

Injured or Deceased removed by:_________________________________________________________

Injured Employee:____________________________ S.S.N#__________________________

Address:____________________________________________________________________________

D.O.B.___/___/____ Date of Hire ___/___/____ No. of Dependents______

Emergency contact notified: Y N Substance Test: Y N Pay Rate:______________

Describe injuries: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Narrative:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________continued Y N

Property Damage: Y N Production Time Lost: Y N Estimated time:__________hrs.

List damaged equipment: (item, ser #, estimated cost)

1.__________________________________________________________________________________2.__________________________________________________________________________________3.__________________________________________________________________________________

PPE involved: Y N PPE collected: Y N Total cost of PPE replacement: $__________________

List PPE items and cost: 1.______________________________________________________________

2.______________________________________________________________

3.______________________________________________________________

4.______________________________________________________________

Pictures taken: Y N

Investigation: Open Closed

S.O.____________________ Investigation Report I.C. #__________________

Involved Persons: (name, ID # if applicable, address, phone #, d.o.b. for non-employee witnesses, attach statements to report form)

Place Involvement Code before Name: W for witness I for involved S for suspect

1.__________________________________________________________________________________2.__________________________________________________________________________________3.__________________________________________________________________________________4.__________________________________________________________________________________5.__________________________________________________________________________________6.__________________________________________________________________________________7.__________________________________________________________________________________8.__________________________________________________________________________________9.__________________________________________________________________________________10._________________________________________________________________________________

Vehicle Information: 1

Make:________________ Model: ______________ License Plate #: ________________________

Color:__________________ Insurance Carrier:_____________________________________________

Estimated Speed of Travel:_________________ Cargo:_____________________________________

GVWR:__________________ Motor Carrier: ______________________________________________

Driver chemical tested? Y N

Other:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Vehicle Information: 2

Make:________________ Model: ______________ License Plate #: ________________________

Color:__________________ Insurance Carrier:_____________________________________________

Estimated Speed of Travel:_________________ Cargo:_____________________________________

GVWR:__________________ Motor Carrier: ______________________________________________

Driver chemical tested? Y N

Other:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

S.O.____________________ Investigation Report I.C. #__________________

Condition of Injured Party :

Had the employee received relevant training? Y N

Date of most recent relevant training? ___/___/___

Hours at work prior to accident? _____________ Time of last break? ______________

Anticipated Lost Time: Y or N Estimated Days: _______

Contributing factors : (circle all that apply) alcohol involvement disregarding safety practice distraction emotional fell asleep inattention lost consciousness medication misjudged clearance

physical disability sick other not detected

Treatment Facility: ____________________________________________ Treated in ER? Y or N

Address: ____________________________________________ Hospitalized Overnight? Y or N

Name of Health Care Professional:___________________________________________

Continued Narrative : ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________continued Y N

Attachments : (circle all that apply) pictures statements test results evidence inventory

List any other attachments:

Evidence Location: _________________

Safety Officer:____________________________

Safety Director:___________________________

S.O.____________________ Investigation Report I.C. #__________________

Draw accident if motor vehicles or fork-trucks are involved. Indicate North by an arrow. Not to scale.

Attach to report.

S.O.____________________ Investigation Report I.C. #__________________

Root Cause: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Immediate Cause:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Recommended Countermeasure:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Copied To: ___________________________

___________________________

___________________________

___________________________

Safety Officer: _______________________________

Safety Director: ______________________________

CONFIDENTIAL