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Incident Investigation Form
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Steps
1.
Supervisor's Report
This section is complete
This section is incomplete
2.
Safety & Risk
This section is complete
This section is incomplete
Supervisor's Report
Name of Employee Involved in Incident:
*
Employee's Phone Number:
*
Date and Time of Incident:
Date and Time of Incident:
Date and Time of Incident:
Date and Time Reported:
Date and Time Reported:
Date and Time Reported:
Department:
*
-- Select One --
City Attorney's Office
City Clerk's Office
City Manager's Office
Community Planning and Development Services
Finance
Human Resources
Information Technology
Police
Public Works
Recreation and Parks
Division:
*
Name of Witnesses:
Witnesses' Phone Numbers:
Exact Location of Incident:
*
Length of Employment:
*
-- Select One --
Less than 1 month
1 - 5 months
6 months - 5 years
Over 5 years
Time Shift Started:
*
Time Shift Started:
Time Shift Started:
Level of training received for specific task:
*
Formal training
On-the-job training
Previous employer experience/training
No training
Level of experience in the specific task:
*
-- Select One --
0 - 6 months
6 - 12 months
1 - 5 years
More than 5 years
Equipment, object or substance involved in incident:
Any Damage to City or Private Property?
*
Yes
No
Please describe:
Photo Documentation:
What task was being performed at the time of the incident?
*
What happened? (e.g. "employee tripped over box" or "forklift hit wall")
*
What were the events leading up to the accident? Describe the sequence in order and when they took place.
Nature of injury and body part (if applicable):
Intial Medical Treatment Rendered:
*
-- Select One --
First Aid
Adventist Urgent Care Visit
Primary Care
No Treatment Rendered
Emergency Room
Other
Other:
Location of Treatment:
Is employee currently out of work?
*
Yes
No
Does the unsafe condition which caused the injury still exist?
Yes
No
Do you question the validity of the injury?
*
Yes
No
Did the injury occur during employee's scope of work?
*
Yes
No
Any other comments related to this incident?
Photo/Documentation
Photo/Documentation
Individual completing report:
*
Date:
*
Date:
Continue
Safety & Risk
Cause of Injury
*
-- Select One --
Burn or Scald - Heat or cold exposure
Caught in or in between
Injured by cut, puncture or scrape
Fall or slip injury
Motor Vehicle - includes mobile equipment
Strain or injury by
Striking against or stepping on
Struck or injuried by
Rubbed or abraded by
Miscellaneous
Details relating to incident.
What factors contributed to the incident?
Check all that apply
Check all that apply
Environment/equipment/materials:
Close clearance/congestion
Lighting
Vibration
Floors/work surfaces
Poor housekeeping
Dust/fume
Slip/trip hazard
Inadequate/improper PPE
Wrong equipment for the job
Inadequate maintenance
Inadequate guarding
Hazardous materials
Defective equipment
Material/equipment too heavy/awkward
Inadequate training provided
Improper material storage
Actions or inactions:
Failure to make secure
Used equipment improperly
Safety controls not used
Failure to use PPE
Improper lifting
Improper position
Inadequate training/supervision
Improper speed
Procedure not followed
Fatigue
Change of routine
Lack of communication
Drugs/alcohol
Time/rushing
Distraction/personal issues/stress
Servicing equipment in motion
Corrective actions to be taken:
Procedural improvement
Identify/improve PPE
Change work methods
Reinstruction of employees
Improve enforcement
Improve storage/arrangement
Improve housekeeping
Use other materials/tools
Complete task analysis
Replace/repair equipment
Install/repair guards
Improve design
Are there any other factors that contributed to the incident?
Recommend corrective actions or preventive measures:
Action Item:
Assigned To:
Estimated Completion Date:
Estimated Completion Date:
Action Item:
Assigned To:
Estimated Completion Date:
Estimated Completion Date:
Action Item:
Assigned To:
Estimated Completion Date:
Estimated Completion Date:
Report Documentation:
Photo Evidence of the Scene
Photo Evidence of the Scene
Photo Evidence of the Scene
Individual Completing Incident Investigation:
*
Date:
*
Date:
Leave This Blank:
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