Employee’s
Incident Report Form
Instructions: Employees will
use this form to report all work-related injuries, illnesses
or “near miss” events (which could have caused an injury or illness)—no matter how minor. This helps to identify and correct hazards
before they cause serious injuries. This
form will be completed by employees as soon as possible and given to a
supervisor for further action.
I am
reporting a work related: q Injury q Illness q Near miss
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Name:
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Job Title:
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Supervisor:
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Have you
told your supervisor about this injury/near miss? q Yes q No
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Date of
injury/illness/near miss:
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Time of
injury/illness/near miss:
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Names of
witnesses (if any):
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Where
exactly did it happen?
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What were
you doing at the time?
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Describe
step by step what led up to the injury/illness/near miss (continue on the
back if necessary):
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What could
have been done to prevent this injury/illness/near miss?
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What parts
of your body were injured? If a near
miss, how could you have been hurt?
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Did you see
a doctor about this injury/illness? q Yes q No
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If yes,
whom did you see?
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Doctor’s
phone number:
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Date:
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Time:
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Has this
part of your body been injured before? q Yes q No
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If yes,
when?
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Supervisor:
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Employee’s
signature:
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Date:
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Supervisor’s
Incident Investigation Form
Name of Injured
Person
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______________________________________________________________
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Date of Birth
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______________
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Telephone Number
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___________________
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Address
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______________________________________________________________
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City
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______________
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State
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___________
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Zip
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_____________
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<> Male <>Female
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What part of the
body was injured? Describe in detail.
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____________________________________________________________________________________
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____________________________________________________________________________________
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What was the
nature of the injury? Describe in
detail.
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____________________________________________________________________________________
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____________________________________________________________________________________
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Describe fully
how the accident happened. What was employee doing prior to the event? What
equipment and tools were being used?
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____________________________________________________________________________________
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____________________________________________________________________________________
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Names
of all witnesses:
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____________________________________________________________________________________
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____________________________________________________________________________________
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Date of Event
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______________
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Time of Event
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____________ am pm
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Exact
location of event:
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____________________________________________________________________________________
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____________________________________________________________________________________
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What caused
the event?
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____________________________________________________________________________________
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____________________________________________________________________________________
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Were safety
regulations in place and used? If not, what was wrong?
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____________________________________________________________________________________
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____________________________________________________________________________________
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Employee
went to doctor/hospital?
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Doctor’s
Name:
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Hospital’s Name:
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Recommended preventive action to
take in the future to prevent reoccurrence:
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____________________________________________________________________________________
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____________________________________________________________________________________
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________________________________________
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________________________________________
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Supervisor’s Signature
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Date
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Incident
Investigation Report
Instructions:
Complete this form as soon as possible after any incident that an
employee reports or which results in serious injury or illness and to
investigate a minor injury or near miss that could have resulted in a serious
injury or illness.
This is a
report of : q Death q Lost Time q Dr. Visit Only q First Aid Only q Near Miss
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Date of
incident:
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This report
is made by: q Employee q Supervisor q Team
q Other_________
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Step 1: Injured employee (complete this part for
each injured employee)
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Name:
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Sex: q Male q Female
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Age:
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Department:
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Job title
at time of incident:
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Part of
body affected: (shade all that apply)
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Nature of
injury: (most serious one):
q Abrasion, scrapes
q Amputation
q Broken bone
q Bruise
q Burn (heat)
q Burn (chemical)
q Concussion (to the head)
q Crushing Injury
q Cut, laceration, puncture
q Hernia
q Illness
q Sprain, strain
q Damage to a body system:
q Other ___________
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This
employee works:
q Regular full time
q Regular part time
q Seasonal
q Temporary
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Months with
this company:
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Months
doing this job:
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Step 2: Describe the incident
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Exact
location of the incident:
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Exact time:
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What part
of employee’s workday? q Entering or leaving work q Doing normal work activities
q During meal period
q During break q Working overtime q Other___________________
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Names of
witnesses (if any):
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Attachments
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Written
witness statements:
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Photographs:
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Maps/drawings:
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What
personal protective equipment was being used (if any)?
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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. Attach separate sheets if
necessary.
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Step 3: Why did the incident happen?
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Unsafe
workplace conditions: (Check all
that apply)
q Inadequate guard
q Unguarded hazard
q Defective safety device
q Defective tool or equipment
q Hazardous workstation layout
q Unsafe lighting
q Unsafe ventilation
q Lack of needed personal protective equipment
q Lack of appropriate equipment/tools
q Unsafe clothing
q No training or insufficient training
q Other:__________________________________
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Unsafe acts
by people: (Check all that apply)
q Operating without permission
q Operating at unsafe speed
q Servicing equipment that has power to it
q Making a safety device inoperative
q Using defective equipment
q Using equipment in an unapproved way
q Unsafe lifting
q Taking an unsafe position or posture
q Distraction, teasing, horseplay
q Failure to wear personal protective equipment
q Failure to use the available equipment/tools
q Other:_______________________________
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Why did the
unsafe conditions exist?
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Why did the
unsafe acts occur?
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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? q Yes q No
If yes, describe:
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Were the
unsafe acts or conditions reported prior to the incident? q Yes q No
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Have there
been similar incidents or near misses prior to this one? q Yes q No
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Step 4: How can future incidents be prevented?
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What
changes do you suggest to prevent this incident/near miss from happening
again?
q Stop this activity
q Guard the hazard
q Train the employee(s) q Train the supervisor(s)
q Redesign task steps
q Redesign workstation
q Write a new policy/rule q Enforce existing policy
q Routinely inspect for the hazard q Personal protective equipment q Other: __________________
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What should
be (or has been) done to carry out the suggestion(s) checked above? Attach
separate sheets if necessary.
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Step 5: Who completed and reviewed
this form? (Please Print)
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Written by:
Department:
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Title:
Date:
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Names of
investigation team members:
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Does team
agree with corrective action recommended in step 4? Yes No N/A
(Step 6
should be completed using investigation team’s final recommendations)
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Reviewed
by:
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Title:
Date:
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Step 6: Corrective Action and
Follow-up
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Written by:
Department:
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Title:
Date:
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List
corrective action to be implemented, date completed and responsible parties.
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Date of
follow-up:
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Conducted
by:
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