Incident report

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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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# Incident Investigation (cont.) ## What is an incident and why should it be investigated? (cont.) The information that follows is intended to be a general guide for employers, supervisors, health and safety committee members, or members of an incident investigation team. When incidents are investigated, the emphasis should be concentrated on finding the root cause of the incident so you can prevent the event from happening again. The purpose is to find facts that can lead to corrective actions, not to find fault. Always look for deeper causes. Do not simply record the steps of the event. Reasons to investigate a workplace incident include: - most importantly, to find out the cause of incidents and to prevent similar incidents in the future - to fulfill any legal requirements - to determine the cost of an incident - to determine compliance with applicable regulations (e.g., occupational health and safety, criminal, etc.) - to process workers' compensation claims The same principles apply to an inquiry of a minor incident and to the more formal investigation of a serious event. Most importantly, these steps can be used to investigate any situation (e.g., where no incident has occurred yet) as a way to prevent an incident. ## Who should do the investigating? Ideally, an investigation would be conducted by someone or a group of people who are: - experienced in incident causation models, - experienced in investigative techniques, - knowledgeable of any legal or organizational requirements, - knowledgeable in occupational health and safety fundamentals, - knowledgeable in the work processes, procedures, persons, and industrial relations environment for that particular situation, - able to use interview and other person-to-person techniques effectively (such as mediation or conflict resolution), knowledgeable of requirements for documents, records, and data collection; and - able to analyze the data gathered to determine findings and reach recommendat…

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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>

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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>