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