incident report form

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# Procedure for Injury or Illness on the Job ## A. Owner or lead person immediately takes charge 1. Supervise and administer first aid as you wish (Good Samaritan Law applies). 2. Arrange for transportation (ambulance, helicopter, company vehicle, etc.), depending on the seriousness of the injury. Protect the injured person from further injury. 3. Notify owner or top management, if not already present. 4. Do not move anything unless necessary, pending investigation of the incident. 5. Accompany or take injured person(s) to doctor, hospital, home etc. (depending on the extent of injuries). 6. Take injured person to family doctor, if available. 7. Remain with the injured person until relieved by other authorized persons (manager, EMT, doctor, etc.). 8. When the injured person's immediate family is known, the owner or supervisor should properly notify family members, preferable in person, or have an appropriate person do so. B. Documentation 1. Minor injuries - requiring doctor or outpatient care: After the emergency actions following an injury, an investigation of the incident will be conducted by the immediate supervisor and any witness to determine the causes. The findings must be documented on our investigation form. 2. Major injuries - fatality, hospitalization, non-hospitalized amputation or loss of an eye(s): Top management must see that L&I is notified as soon as possible, but at least within 8 hours of the incident that caused the fatality or in-patient hospitalization. Also, any non-hospitalized amputation or loss of an eye(s) must be reported to L&I within 24 hours of the incident. - Call L&I at 1-[redacted phone] or visit the nearest L&I office or call OSHA at 1-[redacted phone]. Top management will then assist the Department in the investigation. 3. The findings must be documented on our incident investigation report form and recorded on the OSHA 300 log, if applicable. (Sample incident investigation report form included in this …

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# Basic Rules for Accident Investigation • The purpose of an investigation is to find the cause of an incident and prevent future occurrences, not to fix blame. An unbiased approach is necessary to obtain objective findings. • Visit the incident scene as soon as possible - while facts are fresh and before witnesses forget important details. • If possible, interview the injured worker at the scene of the incident and "walk" him or her through a re-enactment. Be careful not to actually repeat the act that caused the injury. - All interviews should be conducted as privately as possible. Interview witnesses one at a time. Talk with anyone who has knowledge of the incident, even if they did not actually witness the mishap. - Consider taking signed statements in cases where facts are unclear or there is an element of controversy. • Graphically document details of the incident: area, tools, and equipment. Use sketches, diagrams, and photos as needed, and take measurements when appropriate. • Focus on causes and hazards. Develop an analysis of what happened, how it happened, and how it could have been prevented. Determine what caused the incident itself (unsafe equipment/condition, unsafe act, etc), not just the injury. • How will you prevent such incidents in the future? Every investigation should include an action plan. • If a third party or defective product contributed to the incident, save any evidence. It could be critical to the recovery of the claim costs. Use Incident Investigation Report Form - Appendix C 1-3 to write up accident investigation report. 10

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# INCIDENT INVESTIGATION REPORT KEMI Making workers' comp work 1. Injured Employee Information Name Job Title Incident Date 2. Time of Incident OAM OPM 3. Was the incident during the employee's normal work schedule? Yes No ◎ Overtime O 4. Day of Week Mon Tues Wed O 5. Location Thurs Fri Sat◎THE SCHEDE ◎ Please describe the location where the incident occured: 6. Did incident occur on employers' premises? Yes No ◎ 7. Action Taken by Company In Plant First Aid Medical Treatment Lost Work Day 8. Provide an explanation of the incident. (Be specific) 9. Part of Body Affected Head Chest Eye Lungs Ear Abdomen Neck Groin Shoulder Hips Arm Knee Elbow Leg Wrist Ankle Hand Foot Finger Toes Back Other ## 10. Type of Incident Overexertion Fall - Different Level Fall Same Level Struck Against Caught Between Struck By Vehicle Electrical Extreme Temps Repetitive Motion Radiation Absorption Slip (no fall) Twist Other

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# Accident description form Use this form to document information about an accident or incident. Fill out an investigation report as soon as possible. Note: this form is for use within your company. It is not intended to replace DCBS Form 801: Worker's and Employer's Report of Occupational Injury or Disease. Employee(s) name(s): <empty> Time & date of accident/incident: <empty> Job title(s) and department(s): <empty> Supervisor or lead person: <empty> Witnesses: <empty> Brief description of the accident or incident: <empty> Body part affected: <empty> Did the injured employee(s) see a doctor?: [ ] Yes [ ] No If yes, did you file an employer's portion of a worker's compensation form? [ ] Yes [ ] No Did the injured employee(s) go home during their work shift? [ ] Yes [ ] No If yes, list the date and time injured employee(s) left job(s): <empty> Supervisor's Comments: <empty> What could have been done to prevent this accident/incident?: <empty> Have the unsafe conditions been corrected? [ ] Yes [ ] No If yes, what has been done?: <empty> If no, what needs to be done?: <empty> Employer or Supervisor's signature: <empty> Date: <empty> Additional comments/notes: <empty>

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# INCIDENT INVESTIGATION INCIDENT INVESTIGATION Summary Report Address: me: Phone: ## Date Posted: 05/29/2024 Incident investigation is determining the root causes of incidents, on-the-job injuries, property damage, and close calls to prevent them from occurring again. An incident investigation should lead you to the real cause of why something happened, and armed with that knowledge, you can take affirmative steps to prevent future incidents from occurring. In addition to the root cause, several causal factors may contribute to the incident. These will be evidenced in the answers to the "why" questions. Several factors may have contributed to the root cause, and correctly identifying them will help you develop a plan to mitigate the hazard in the future. ## WHAT IS AN INCIDENT? An event resulting in personal injury, property damage, equipment damage, impact to environmental resources, loss of production or product, or an event that has the potential to cause significant injury, damage, loss, or effect to environmental resources. ## WHY SHOULD INCIDENTS BE INVESTIGATED? Prevention is the purpose of an investigation. An incident investigation should: • Determine what happened. - Determine the cause or causes of the incident. . Identify any unsafe conditions, acts, or procedures. • Help management to identify practical corrective actions. - Determines whether due diligence was observed. • - Show the commitment of management that an adequate investigation system is in place. An incident investigation should not strive to determine fault or blame but to identify the primary causes of incidents so that controls can be implemented to prevent further occurrences. ## INCIDENT INVESTIGATION STEPS Preserve and Document the Incident Scene: Before anything occurs, one must ensure that the incident scene secure and does not present further potential for environmental damage or harm to those around. Gather Information: As little time as possible should be lost…

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# Incident Investigation Report Form (cont.) ## Step 1: Injured employee (complete this part for each injured employee) (cont.) 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?: [ ] Yes [ ] No If yes, describe:<empty> Were the unsafe acts or conditions reported prior to the incident?: [ ] Yes [ ] No Have there been similar incidents or near misses prior to this one?: [ ] Yes [ ] No ## Step 4: How can future incidents be prevented? What changes do you suggest to prevent this injury/near miss from happening again? 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? Description continued on attached sheets: Step 5: Who completed and reviewed this form? (Please Print) Written by: <empty> Title: <empty> Department: <empty> Date: <empty> Names of investigation team members: <empty> C-3

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CCOHS CCHST Canadian Centre for Occupational Health and Safety Centre canadien d'hygiène et de sécurité au travail Health and Safety Programs # Incident Investigation ## On this page What is an incident and why should it be investigated? Who should do the investigating? Should the immediate supervisor be on the team? Why look for the root cause? What are the steps involved in investigating an incident? What should be looked at as the cause of an incident? How are the facts collected? What should I know when making the analysis and recommendations? Why should recommendations be made? What should be done if the investigation reveals human error? How should follow-up be done? ## What is an incident and why should it be investigated? The term incident can be defined as an occurrence, condition, or situation arising in the course of work that resulted in or could have resulted in injuries, illnesses, damage to health, or fatalities. The term "accident" is also commonly used, and can be defined as an unplanned event that interrupts the completion of an activity, and that may (or may not) include injury or property damage. Some make a distinction between accident and incident. They use the term incident to refer to an unexpected event that did not cause injury or damage that time but had the potential. "Near miss" or "dangerous occurrence" are also terms for an event that could have caused harm but did not. Please note: The term incident is used in some situations and jurisdictions to cover both an "accident" and "incident". It is argued that the word "accident" implies that the event was related to fate or chance. When the root cause is determined, it is usually found that many events were predictable and could have been prevented if the right actions were taken - making the event not one of fate or chance (thus, the word incident is used). For simplicity, we will now use the term incident to mean all of the above events. Incident Investigation CCOHS

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# INCIDENT INVESTIGATION REPORT (cont.) ## 11. Did the employee report any of the following? Back Strain Sprain Dislocation Fracture Contusion Amputation Open Wound Burn Asphyixia Hearing Loss Foreign Body Multiple Injury Cumulative Trauma Other 12. After printing, use this area to illustrate the incident. (if applicable) 13. Personal Protective Equipment (PPE) in use at the time of the incident. 14. Note any additional information or recom- mendations. Employee: <empty> (Signature) Date: <empty> Completed by: <empty> (Signature) Title: <empty> Date: <empty>