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Accident Report PDF

This incident report form is used to document incidents that result in serious injury, illness, or near misses. It collects information about the injured employee, details of the incident including location and witnesses, and seeks to identify the unsafe workplace conditions and acts that may have led to or contributed to the incident. The report aims to understand why unsafe conditions existed, why unsafe acts occurred, and whether there were any rewards or prior reports that could have helped prevent the incident.

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Adriana Lima
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480 views2 pages

Accident Report PDF

This incident report form is used to document incidents that result in serious injury, illness, or near misses. It collects information about the injured employee, details of the incident including location and witnesses, and seeks to identify the unsafe workplace conditions and acts that may have led to or contributed to the incident. The report aims to understand why unsafe conditions existed, why unsafe acts occurred, and whether there were any rewards or prior reports that could have helped prevent the incident.

Uploaded by

Adriana Lima
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Incident Investigation Report

Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness.
(Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)

This is a report of a: ‰ Death ‰ Lost Time ‰ Dr. Visit Only ‰ First Aid Only ‰ Near Miss

Date of incident: This report is made by: ‰ Employee ‰ Supervisor ‰ Team ‰ Other_________

Step 1: Injured employee (complete this part for each injured employee)
Name: Sex: ‰ Male ‰ Female Age:
Department: Job title at time of incident:
Part of body affected: (shade all that apply) Nature of injury: (most This employee works:
serious one) ‰ Regular full time
‰ Abrasion, scrapes ‰ Regular part time
‰ Amputation ‰ Seasonal
‰ Broken bone ‰ Temporary
‰ Bruise
Months with
‰ Burn (heat)
this employer
‰ Burn (chemical)
‰ Concussion (to the head) Months doing
‰ Crushing Injury this job:
‰ Cut, laceration, puncture
‰ Hernia
‰ Illness
‰ Sprain, strain
‰ Damage to a body system:
‰ Other ___________

Step 2: Describe the incident


Exact location of the incident: Exact time:
What part of employee’s workday? ‰ Entering or leaving work ‰ Doing normal work activities
‰ During meal period ‰ During break ‰ Working overtime ‰ Other___________________
Names of witnesses (if any):

3
Number of Written witness statements: Photographs: Maps / drawings:
attachments:
What personal protective equipment was being used (if any)?

Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials
and other important details.

Description continued on attached sheets: ‰

Step 3: Why did the incident happen?


Unsafe workplace conditions: (Check all that apply) Unsafe acts by people: (Check all that apply)
‰ Inadequate guard ‰ Operating without permission
‰ Unguarded hazard ‰ Operating at unsafe speed
‰ Safety device is defective ‰ Servicing equipment that has power to it
‰ Tool or equipment defective ‰ Making a safety device inoperative
‰ Workstation layout is hazardous ‰ Using defective equipment
‰ Unsafe lighting ‰ Using equipment in an unapproved way
‰ Unsafe ventilation ‰ Unsafe lifting
‰ Lack of needed personal protective equipment ‰ Taking an unsafe position or posture
‰ Lack of appropriate equipment / tools ‰ Distraction, teasing, horseplay
‰ Unsafe clothing ‰ Failure to wear personal protective equipment
‰ No training or insufficient training ‰ Failure to use the available equipment / tools
‰ Other: _____________________________ ‰ Other: __________________________________

Why did the unsafe conditions exist?

Why did the unsafe acts occur?

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:

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

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