ES Plastics
Accident/Incident/Injury Investigation Procedures
All injuries, no matter how slight, will be reported to the immediate
supervisor. Should injury require first aid treatment, it will be given
immediately; each crew member will become as familiar as possible with the
principles of first aid.
All injuries which occur during the course of employment must be reported
on the appropriate Incident/Injury form (copies attached). All sections of the
form must be completed with correct and concise information.
Incident Investigation Procedures
An incident investigation will be performed by the supervisor at the location
where the incident occurred. All incidents should be reported and
investigated, regardless of whether an injury resulted from the incident. The
safety coordinator is responsible for seeing that the incident investigation
reports are being filled out completely, and that the recommendations are
being addressed. Supervisors will investigate all incidents, injuries, and
occupational diseases using the following investigation procedures:
Implement temporary control measures to prevent any further injuries to
employees
Review the equipment, operations, and processes to gain an
understanding of the incident
Identify and interview each witness and any other person who might
provide clues to the incident’s causes
Investigate causal conditions and unsafe acts; make conclusions based on
existing facts
Complete the incident investigation report
Provide recommendations for corrective actions
Indicate the need, when appropriate, for additional or remedial safety
training
Incident investigation reports must be submitted to the safety coordinator
within 24 hours of the incident
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Instructions for Completing the Incident
Investigation Report
An Incident Investigation is not designed to find fault or place blame but is
an analysis of the incident to determine causes that can be controlled or
eliminated. All sections of the form are to be completed. If a section does
not apply, indicate with “N/A”.
(Items 1-6) Identification: This section is self-explanatory.
(Item 7) Nature of Injury: Describe the injury; e.g. strain, sprain, cut burn,
fracture. Injury type: First aid - injury resulted in minor injury/treated on
premises; Medical - injury treated off premises by physician; Lost time -
injured missed more than one day of work; No Injury - no injury, near-miss
type of incident.
Part of the Body: part of the body directly affected; e.g. foot, arm, and
head.
(Item 8) Describe the Incident: Describe the incident, including exactly
what happened and where and how it happened. Describe the equipment or
materials involved.
(Item 9) Cause of Incident: Describe all conditions or acts which
contributed to the incident; i.e.
Unsafe conditions - spills, grease on the floor, poor housekeeping or
other physical conditions.
Unsafe acts - unsafe work practices such as failure to warn, failure to
use required personal protective equipment, or violation of existing
safety rules(s).
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(Item 10) Personal protective equipment: Self-explanatory
(Item 11) Witness(es): List name(s), address(es), and phone number(s).
(Item 12) Safety training provided: Was any safety training provided to
the injured related to the work activity being performed?
(Item 13) Interim corrective action: Measures taken by supervisor to
prevent recurrence of incident; i.e. barricading incident area, posting
warning signs, shutting down operations.
(Item 14): Self-explanatory
(Item 15): Self-explanatory
(Item 16): Follow-up: Once the investigation is complete, the safety
coordinator will review and follow-up the investigation to ensure that
corrective actions recommended by the safety committee and approved by
the employer are taken, and control measures have been implemented.
Incident Investigation Report Report # ______________
COMPANY___________________________________________________________
ADDRESS: ____________________________________________________________
Street
City
State
Zip Code
1. Name of Injured: _____________________________ SSN: _____-_____-______
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2. Sex: { } M { } F Age: ____ Date of
Incident________________________
3. Time of Incident: ____a.m. ____p.m. Day of Incident:
_____________________
4. Employee’s job title__________________________________________________
5. Length of experience of job: _______ Years ______ Months
6. Address of location where the incident occurred:
___________________________
_____________________________________________________________________
7. Nature of injury, injury type, and part of the body affected:
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________
8. Describe the Incident and how it occurred:
________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________
9. Cause of Incident:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________
_____________________________________________________________________
10. Was personal protective equipment required? { } yes { } no
Was it provided? { } yes { } no
Was it being used? { } yes { } no If “no” explain
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________
Was it being used properly as trained by supervisor or designed by
trainer? { } yes { } no
If “no” explain
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________
11. Witness(es):
______________________________________________________________________________
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______________________________________________________________________________
___________________________________________________
12. Safety training provided to the injured? { } yes { }no If “no” explain
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________
13. Interim Corrective action to prevent recurrence:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________
14. Permanent Corrective Action recommended preventing recurrence:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________
15. Date of Report: __________________Prepared By: _______________________
Supervisor _______________________________ Date: ___________________
Signature
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16. Status and follow-up action taken by safety coordinator:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________-
_______________________________________
________________________________________________________________________
________________________________________________________
_____________________________________________________________________-
___________________________________________________________
Safety Coordinator _________________________ Date:
____________________
Signature
ADDITIONAL NOTES
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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