Easy assignments - Need in 6-8 Hours.Safety Management Systems

Investigation Report I.C. #__________________ Open/Closed

Date of Incident: ___/___/___ Date of Report: ___/___/___ Dept: _________________

Time of Incident: _________ Time of Report: __________ Shift:_________________

Location or Machine #:________________________________________________________

Environmental Conditions:(circle) Indoor or Outdoor Temp. _____ WBGT. ____ Wind Speed____

General Description:(circle) rain snow ice icy wet dry cloudy sunny windy fog dusty

Lighting: (circle) dawn daylight dusk dark- outside lighting on indoor plant lighting on

dark- outside lighting off indoor plant lighting off

dark- outside lighting inop indoor plant lighting inop

First Aid at scene: yes no First Aid provider:________________________

Injured removed to:_______________________________________________

Injured or Deceased removed by:_________________________________________________________

Injured Employee:____________________________ S.S.N#__________________________

Address:____________________________________________________________________________

D.O.B.___/___/____ Date of Hire ___/___/____ No. of Dependents______

Emergency contact notified: Y N Substance Test: Y N Pay Rate:______________

Describe injuries: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Narrative:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________continued Y N

Property Damage: Y N Production Time Lost: Y N Estimated time:__________hrs.

List damaged equipment: (item, ser #, estimated cost)

PPE involved: Y N PPE collected: Y N Total cost of PPE replacement: $__________________

List PPE items and cost: 1.______________________________________________________________

2.______________________________________________________________

3.______________________________________________________________

4.______________________________________________________________

Pictures taken: Y N

S.O.____________________ Investigation Report I.C. #__________________

Involved Persons: (name, ID # if applicable, address, phone #, d.o.b. for non-employee witnesses, attach statements to report form)

Place Involvement Code before Name: W for witness I for involved S for suspect

1.__________________________________________________________________________________2.__________________________________________________________________________________3.__________________________________________________________________________________4.__________________________________________________________________________________5.__________________________________________________________________________________6.__________________________________________________________________________________7.__________________________________________________________________________________8.__________________________________________________________________________________9.__________________________________________________________________________________10._________________________________________________________________________________

If vehicles are involved on roadway attach police report; draw scene; take pictures
If equipment is involved, include drawing, pictures, recall/maintenance history

Vehicle Information: 1

Make:________________ Model: ______________ License Plate #: ________________________

Color:__________________ Insurance Carrier:_____________________________________________

Estimated Speed of Travel:_________________ Cargo:_____________________________________

GVWR:__________________ Motor Carrier: ______________________________________________

Driver chemical tested? Y N Recall History:_____________________________________________

Other:__________________________________________________________________________________________________________________________________________________________________Maintenance:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Vehicle Information: 2

Make:________________ Model: ______________ License Plate #: ________________________

Color:__________________ Insurance Carrier:_____________________________________________

Estimated Speed of Travel:_________________ Cargo:_____________________________________

GVWR:__________________ Motor Carrier: ______________________________________________

Driver chemical tested? Y N Recall History:_____________________________________________

________________________________________________________________________________________________________________________________________________________________________

Incident Map

S.O.____________________ Investigation Report I.C. #__________________

Condition of Injured Party:

Had the employee received relevant training? Y N

Date of most recent relevant training? ___/___/___

Hours at work prior to accident? _____________ Time of last break? ______________

Anticipated Lost Time: Y or N Estimated Days: _______

Treatment Facility: ____________________________________________ Treated in ER? Y or N

Address: ____________________________________________ Hospitalized Overnight? Y or N

Name of Health Care Professional:___________________________________________

Continued Narrative: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________continued Y N

Attachments: (circle all that apply) supplement pictures statements test results evidence inventory

List any other attachments:

Causal Analysis

Event:			Sequence Before/After
______________________________________________________________________________________________

Constant Environmental Conditions:

o Indoor	o Windy	Notes:/Other:
o Outdoor	o Fog
o Debris on ground/floor	o Dusty
o Rain	o Dawn
o Snow	o Day
o Ice	o Night
o Wet	o Temperature .
o Dry	o Lights turned on
o Cloudy	o Lights turned off
o Sunny	o Lights inoperable
____________________________________________________________________________________________
	Unsafe Acts			Substandard Conditions



Immmediate Cause


	Job Factors	Personal Factors			Mgt System Factors
Root Cause:

Evidence/Material Disposition

Case #_________________ Description:___________________________________________________

Item Description From Secure Date In Date Out

Location To Whom?

Narrative:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Item Description Date Out/ Date In Person Receiving Modification

	/

(note significance of material/evidence; any person taking possession of material/evidence must sign out and sign in material / evidence to verify no modification or document modifications)

S.O.____________________ Investigation Report I.C. #__________________

Draw accident if motor vehicles or fork-trucks are involved. Indicate North by an arrow. Not to scale.

Attach to report.

Executive Summary

Case:_________________ Open/Closed Date of Incident:____/____/______

Facts:

Causal Analysis:

Countermeasures:

Project Breakdown:

Confidential Page __ of ___