Privileged and Confidential Incident Investigation Report To County Counsel Section I –Investigator Information 1. County Employee Investigating Incident: a) Name:____________________________ b) Title:______________________________ c) Phone:____________________________ Department: Investigation was initiated: Date: Location (Department) Code: Time: Section II –Type of Incident 2. (select one) Hazard Observation Near Mishap Primary type of incident: Injury Illness Chemical Spill or Release *Vehicle NonDOT *Vehicle DOT Environmental Property Damage Fire Explosion Security Workplace Violence Other * Attach a completed Vehicle and Property Damage Incident Report. Section III - Information of Employee Involved: Injury? No Yes* 2a. OSHA Recordability of Injury/Illness (*OSHA Recordable) (**OSHA Reportable) First Aid – non-medical – Notice Only First Aid – Medical Medical Only* Restricted Workday* Lost Workday* Hospitalization** Fatality** N/A *Request injured employee to complete a written Report of Employee Incident *If more than one injured party, complete information below separately for each injured party; add additional pages as necessary. 3. Employee’s Full Name: 3a.Employee’s Address: Street City State ZIP 3b. Phone Number: 4. Employee’s Date of Birth: 6. Job Title: 10. Date of Incident: 10a. Time of Incident 11. Date Incident was Reported: 4a. Male Female 7. Hours Worked/Week 10b. Time Employee Began Work: 5. Employee’s Date of Hire: 12. Date Last Worked: 13. Employee’s Years of Experience in Current Job 15. Salary Continuation: Yes No 14. Employment Status: 8. Days 9. Hours Worked/Day Worked/Week 10c. Employee’s Time on 10d. Job Task: Task (hours): 16. Paid for Day of Injury? Yes No 18. Date DWC-1 Provided to employee: 17. Lost work days: Yes First full day disabled: 19. Type of Employer: County Government If employee sought medical treatment – Complete information of the Physician or Other Health Care Provider 20. Name of Physician or other Health Care Professional: 21. If treatment was given away from the worksite, where was it given? 22. Facility Street City 23. Treated in an emergency room? Yes No 24. Hospitalized overnight as an in-patient/fatality? Yes** No (Complete §342 - Fatality/Serious Injury Report Form within one hour)** State ZIP 25. County authorized facility? Yes No Information regarding location of incident. 26. Facility Condition: Normal Project Work Routine Maintenance Shutdown Maintenance Upset Condition 27. Department where event or exposure occurred: 28. Exact Location of Incident (Number, Street, City, Zip): 29. Equipment (including PPE), materials and chemicals the employee was using when event or exposure occurred: 30. Specific activity the employee was performing when event or exposure occurred: Page 1 of 5 Privileged and Confidential No Privileged and Confidential Incident Investigation Report To County Counsel 31. List all witnesses (Request a written Incident Witness Statement of all witnesses and attach to this report.) : 32. Who else was involved? Section IV - Remaining sections pertaining to factual sequence of events: 33. How injury/Illness occurred. Sequence of Events (Describe what happened before, during and after the incident, what part of the body was injured, what property was damaged, any tools, materials, chemicals being used and/or environment condition at the time of the incident. Use additional sheets if necessary.) Do not copy/paste the employees’ written statement. Use all data gathered to develop sequence of events. 34. What did the employee state could be done to prevent the incident? Page 2 of 5 Privileged and Confidential Privileged and Confidential Incident Investigation Report To County Counsel 35. What do you (Supervisor) think could be done to prevent this incident? 36. Primary Type of Contact: (select all that apply) a. Absorption e. Inhalation, Swallowing i. Slip, Trip, Fall b. Bodily Reaction f. Overexertion (lifting) j. Struck Against/Struck By c. Caught In, Under or Between g. Repetitive Motion k. Temperature Extremes d. Exposure to, Contact with h. Rubbed or Abraded l. Other______________ Section V - Causal Analysis (see Guide for Identifying Causal Factors and Corrective Actions) 37. Behaviors: (select all that apply) a. b. c. d. e. f. g. h. i. j. k. l. m. n. Authority to Operate Equipment Awareness of Surroundings Clothing (other than P.P.E.) Driver Actions Drugs or Alcohol Equipment Operator Actions Failure to Secure Grip or Hold Horseplay or Fighting Intentional Act/Sabotage Lifting, pushing, or pulling Loading or stacking Lockout / Tag Out Speeding a. Environmental Conditions (gases, dusts, smoke, fumes) Equipment Failure Exposure to cold temperatures Exposure to hot Temperatures Fire / Explosion Guards or Barriers Housekeeping Illumination Labeling New or Modified Equipment New or Modified Procedure 38. o. p. q. r. s. t. u. v. w. x. y. z. aa. bb. Mixing or combining of substances Mobile Radio/Cell Phone Use Need for Assistance Operating Speed P.P.E Placement or Storage Positioning for Task Safe work practices or rules Safety Devices Servicing Equipment in Operation Use of Equipment Use of equipment or tools Warning or Instruction Other _____________________ Conditions: (select all that apply) b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. q. r. s. t. u. v. Noise Protective Equipment Radiation Tools/equipment availability Ventilation Vibration Visibility Walking or Working surface Warning Systems Weather Conditions Workspace Conditions (congested or restricted access/egress) w. Other_______________________ Page 3 of 5 Privileged and Confidential Privileged and Confidential Incident Investigation Report To County Counsel 39. Write a brief description for each box checked above in the Causal Analysis section. You may use the Guide for Identifying Causal Factors and Corrective Actions (i.e. Awareness of Surroundings – Employee tripped on the parking block In the parking lot. The incident occurred at 3:30pm on a normal sunny day. Employee was reading a memo while walking to his car. He was not attentive to his surroundings and in the process tripped over the parking block.) 40. Basic or Root Causes: (select all that apply) a. Abuse or misuse b. c. d. e. f. g. h. i. j. Employee knowledge Employee Skill Engineering or Design Inspections Maintenance Management Systems Mental Stress or Fatigue Mental or Psychological Capability Motivation k. l. m. n. o. p. q. r. s. t. u. Physical Capability Physical Stress or fatigue Procurement/Purchasing Risk Assessment Supervision or Leadership Tools, Equipment, or Materials Training Retraining Wear and Tear Work Standards or Procedures Other________________________ 41. Write a brief description for each box checked above. You may use the Guide for Identifying Causal Factors and Corrective Actions (i.e. Training – The department has not provided training to employee on slip/trip and fall for more than a year.) Section VI – Corrective Actions 42. Corrective Actions (actions short term, intermediate, and long term) Use the Follow up Report to document. i.e.: By who By when 1. 1. 2. 1. 2. 2. Train all employees on slip/trip and fall. Ensure to include training on Slips/Trips and Falls as part of an annual refresher.. John Doe Jane Doe Section VII – Investigation Review and Approval 43. Department Safety Representative Date Page 4 of 5 Privileged and Confidential 7/25/08 7/25/08 Privileged and Confidential Incident Investigation Report To County Counsel 44. Supervisor’s Signature Date 45. Division Manager/Director’s Signature Date 46. Department Head’s Signature (for all incidents with restricted work or more serious) Date 47. County Safety Officer’s Signature (for all incidents with restricted work or more serious) Date 48. CAO’s Signature (all incidents involving a fatality) Date Page 5 of 5 Privileged and Confidential
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