Get documents about "Name of Person Reporting Incident
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Safety & Loss Control - Incident Investigation Report Form
Name of Person Investigating Incident: Department: Date Investigation was
Location (Department) Code: initiated:
Incident Information
Section I
Primary type of incident: (select one) OSHA Recordability of Injury/Illness
(*OSHA Recordable)
Injury Hazard Observation Vehicle Non-DOT
First Aid Medical
Illness Near Mishap Vehicle DOT
Chemical Spill or Release Property Damage Other Restricted Workday*
Environmental Security
Lost Workday* Fatality* N/A
Fire Explosion Workplace Violence
This section to be completed for all Injuries or Illnesses by injured employee or employee reporting an
injury/property damage involving a member of the public:
Does the incident involve a County employee Yes No Other Explain:____________________________________
*If more than one injured party, complete information below separately for each injured party; add additional pages as necessary.
Date of Incident: Time of Incident Time Employee Began Work: Date Incident was Reported: Date Last Worked:
Injured Person(s) Full Name: Injured Person(s) Address:
Street City State ZIP
Phone Number:
Injured Person(s) Date of Birth: Injured Person(s) Date of Hire:
Male Female
Job Title: Hours Worked/Week Days Worked/Week Hours Worked/Day
Injured Person(s) Time on Task (hours): Job/Task Injured Person(s) Years of Experience in Current Job
Department where event or exposure occurred:
Exact Location of Incident (Number, Street, City, Zip):
Equipment (including PPE), materials and chemicals the employee was using when event or exposure occurred:
Specific activity the employee was performing when event or exposure occurred:
What caused the incident? (Use additional paper if needed.)
List all witnesses:
Who else was involved?
What could have been done to prevent Incident? (Use additional paper if needed.)
Describe what part of your body was affected and the symptoms you presently have:
On the diagrams that follow mark an (X) on the places you have a visible injury.
Circle the area of discomfort:
Injured Person’s Signature: Date:
Front Back
Page 1 of 4
(Revised 12/1/2010)
Distribution List: □ Employee Incident File □ Division Manager □ Department Head □ Risk Management
Safety & Loss Control - Incident Investigation Report Form
Section II - This remaining sections to be completed by the Supervisor or Incident Investigator:
Employment Status: Salary Continuation: Paid for Day of Injury? Lost work days: Yes No Date last worked:
Yes No Yes No First full day disabled:
Date DWC-1 Provided to employee: __________ Type of Employer: County Government
Facility Condition
Normal Project Work Routine Maintenance Shutdown Maintenance Upset
Claim Authorization Number (ENTER number provided by LM Intake Personnel): ________________________________
Information About the Physician or Other Health Care Professional
Name of Physician or other Health Care Professional:
If treatment was given away from the worksite, where was it given?
Facility Street City State ZIP
Treated in an emergency room? Hospitalized overnight as an in-patient? County authorized facility? Yes No
Yes No Yes No
Supervisor’s Signature: Date:
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.
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______________
Page 2 of 4
(Revised 12/1/2010)
Distribution List: □ Employee Incident File □ Division Manager □ Department Head □ Risk Management
Safety & Loss Control - Incident Investigation Report Form
Section III - Causal Analysis (see Guide for Identifying Causal Factors and Corrective Actions)
Behaviors: (select all that apply)
1. Authority to Operate Equipment 14. Mixing or combining of substances
2. Awareness of Surroundings 15. Mobile Radio/Cell Phone Use
3. Clothing (other than P.P.E.) 16. Need for Assistance
4. Driver Actions 17. Operating Speed
5. Drugs or Alcohol 18. P.P.E
6. Equipment Operator Actions 19. Placement or Storage
7. Failure to Secure 20. Positioning for Task
8. Grip or Hold 21. Safe work practices or rules
9. Horseplay or Fighting 22. Safety Devices
10. Intentional Act/Sabotage 23. Servicing Equipment in Operation
11. Lifting, pushing, or pulling 24. Use of Equipment
12. Loading or stacking 25. Use of equipment or tools
13. Lockout / Tagout 26. Warning or Instruction
27. Other _____________________
Conditions: (select all that apply)
28. Environmental Conditions (gases, dusts, smoke, 39. Noise
fumes) 40. Protective Equipment
29. Equipment Failure 41. Radiation
30. Exposure to cold temperatures 42. Tools/equipment availability
31. Exposure to hot Temperatures 43. Ventilation
32. Fire / Explosion 44. Vibration
33. Guards or Barriers 45. Visibility
34. Housekeeping 46. Walking or Working surface
35. Illumination 47. Warning Systems
36. Labeling 48. Weather Conditions
37. New or Modified Equipment 49. Workspace Conditions (congested or restricted
38. New or Modified Procedure access/egress)
50. Other_______________________
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.)
Page 3 of 4
(Revised 12/1/2010)
Distribution List: □ Employee Incident File □ Division Manager □ Department Head □ Risk Management
Safety & Loss Control - Incident Investigation Report Form
Basic or Root Causes: (select all that apply)
51. Abuse or misuse 61. Physical Capability
52. Employee knowledge 62. Physical Stress or fatigue
53. Employee Skill 63. Procurement/Purchasing
54. Engineering or Design 64. Risk Assessment
55. Inspections 65. Supervision or Leadership
56. Maintenance 66. Tools, Equipment, or Materials
57. Management Systems 67. Training
58. Mental Stress or Fatigue 68. Retraining
59. Mental or Psychological Capability 69. Wear and Tear
60. Motivation 70. Work Standards or Procedures
71. Other________________________
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 IV – Corrective Actions
Corrective Actions (actions short term, intermediate, and long term (i.e. By who By when
1. Train all employees on slip/trip and fall. 1. John Doe 1. 7/25/08
2. Ensure to include Slip/Trip and Fall training as part of an annual refresher tailgate 2. Jane Doe 2. 7/25/08
meeting.)
Section V – Investigation Review and Approval
Incident Investigator Date
Department Safety Representative Date
Supervisor’s Signature Date
Division Manager/Director’s Signature Date
Department Head’s Signature (for all incidents with restricted work or more serious) Date
County Safety Officer’s Signature (for all incidents with restricted work or more serious) Date
CAO’s Signature (all incidents involving a fatality) Date
Page 4 of 4
(Revised 12/1/2010)
Distribution List: □ Employee Incident File □ Division Manager □ Department Head □ Risk Management
