Easy assignments - Need in 6-8 Hours.Safety Management Systems
jhayes
fitchettinvform.docx
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Part 1: Employee Information |
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Name of Employee |
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Employee Number |
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Company |
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Date of Incident |
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Department/ Classification |
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Time of Incident |
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Age of Employee |
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Years of Experience |
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Part 2: Incident Information |
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Type of Injury |
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Part of Body |
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Medical Attention |
YES NO |
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Severity of Injury |
Circle Below: Near Miss/Report Only First Aid OSHA Lost Time* Fatality Property Damage |
* If Lost Time - Days Lost |
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Restricted Days |
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Medical Follow-up |
YES NO |
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Additional Information |
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Date(s) of Medical Follow-up |
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* If additional personnel were affected copy this sheet and attach.
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Executive Summary
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Incident Investigation Team Members:
Executive/Management Sponsor:
Safety Professional:
SME:
Union Rep:
Additional Name(s)/Title:
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Executive / Manager Signature |
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Date |
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Use Proper Analysis Tool Kit (at a minimum, circle all used in initial investigation )
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Digital / Video Camera |
Sample Bottle / tags / plastic bags / tape |
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Procedures / drawings / Manuals / MSDS |
Direct Reading Instruments i.e. gas detector, hot stick, etc. |
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Notebooks/Graph paper |
Flashlight & batteries |
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ruler/tape measure |
Barricades, ropes/tape |
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Other: |
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Part 3: Incident Information |
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What happened? Sequence of Events (use separate sheet for all involved and witnesses) |
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When did it happen? |
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Where did the incident occur? |
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Who was involved? |
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How did it happen? |
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Why did it happen? |
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How can we keep this from happening again? |
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What tools/equipment was involved? |
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Were there witnesses? (document their statement on separate sheet and attach) |
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Was this a routine evolution? |
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Have you been trained on this task? If so how frequently? |
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Process/Procedure Involved |
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Has this occurred prior? Yes, was it documented? (list incident tracking number(s) below) NO |
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Diagram of area
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Incident Investigation Report Report Tracking No. 20___-_____
Page 6 of 6
Cause and Recommendations derived from information gathered from investigation
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Direct Cause of Incident:
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Contributing Cause(s) of Incident:
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Final Recommendation(s) Summary:
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1 |
Recommendation:
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Actions - |
Due Date |
Owner |
Status |
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1A |
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1B |
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2 |
Recommendations:
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Actions - |
Due Date |
Owner |
Status |
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2A |
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2B |
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3 |
Recommendations:
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Actions - |
Due Date |
Owner |
Status |
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3A |
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3B |
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4 |
Recommendations:
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Actions - |
Due Date |
Owner |
Status |
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4A |
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4B |
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List additional documentation
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(Example: Attachment 1 – Photo 1, or MSDS, etc.) |
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Additional Information / Follow-up Information |
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Continue with additional sheets if necessary |
