INCIDENT INVESTIGATION THE MINIMUM QUESTIONS TO THE SOLUTION

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					INCIDENT INVESTIGATION THE MINIMUM QUESTIONS TO THE SOLUTION

INCIDENT INVESTIGATION: Checklist of information and Analysis
     Description of Injured:
     Employee Number:
     Last Name: First Name: Initial:
     Age: __ Length of service: Length of service on present job:
     Safety training received: Date safety training received:
     Supervisor in charge at time of accident:
     Names of any witnesses:

Information: Description of Accident
      Location: Date Time:
      Accident type:
      Machinery/Equipment involved:
      Date of last service/inspection:
      Were people involved?
      What type of Environment:
      Was ventilation adequate?
      State of working surfaces:
      Were chemicals involved in accident?
      Details:
      Any other factors involved in accident:

The Injury:
      Nature?
      Was First Aid administered?
      Was hospital treatment required?
      Length of time away from work:

Days

       Was the injured wearing specified PPE at time of accident?
       Was task authorized?
       Specify any legal regulations which related to any of the circumstances
       surrounding the
       accident:
       Have any similar accidents occurred before in the above location?

       DATE DESCRIPTION
       Has a member of the health and safety committee investigated this accident?
       (if yes, attach his/her findings):

Findings:
Analysis of Causes:
1. Name persons interviewed as part of this investigation: State briefly their
observations as to causes:
NAME                                    OBSERVATIONS




2. From all the information contained in Part 1 and from observations obtained from
interviews, inspections of workplace, equipment involved, list all possible and
probable causes. (Note: Direct, contributing and underlying causes to be included,
e.g., if machine guard missing, state why this happened)

List these causes as they may relate to all or any of the following:
Organization (including company policy, procedures, training, supervision,
maintenance, purchasing, controls, etc.):
        Machinery/Equipment:
        Working practices:
        Environmental factors: -

Recommendations: List recommendations for changes in any of above necessary to
prevent a recurrence of this accident or other accidents which may result from
defects noted above.

				
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posted:7/25/2010
language:English
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