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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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# Accident investigation form (example 1) List each corrective action to be taken. Who will do it and when will it be done? - 1. 2. - 3. - 4. - 5. - 6. 7. Attach photographs, sketches of the scene, or other relevant information. Prepared by: Title: Date: 2

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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>