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					              Safety & Loss Control - Incident Investigation Report Form

Name of Person Investigating Incident:            Site (location):                                                Date Investigation was
                                                                                                                  initiated:

                                                  Incident Information
Primary type of incident: (select one)

    Injury                                               Hazard Observation                               Vehicle Non-DOT
    Illness                                              Near Mishap                                      Vehicle DOT
    Chemical Spill or Release                            Property Damage                                  Other
    Environmental                                        Security
    Fire Explosion                                      Workplace Violence

OSHA Recordability of Injury/Illness (*OSHA Recordable)

   First Aid        Medical        Restricted         Lost Workday*        Fatality*          N/A
                     Treatment       Workday*
This section to be completed for all Injuries or Illnesses: County Employee                Yes       No    Other____________
*If more than one injured party, complete information below for each injured party; add additional pages as necessary.
Person(s) Full Name:                          Person(s) Address:
                                              Street                                   City                  State    ZIP

Injured Person(s) Date of Birth:                                                Injured Person(s) Date of Hire:
                                                  Male          Female
Injured Person(s) Time on Task (hours):        Job/Task                         Injured Person(s) Years of Experience in Current Job

Exact Location of Incident:


Facility Condition
   Normal          Project Work               Routine Maintenance           Shutdown Maintenance                   Upset
Date of Incident:          Time of Incident                   Date Reported:                        Date of Investigation:

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?
   Yes       No                                      Yes      No
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.




                                                          Page 1 of 3

       Distribution List: □ Employee Incident File □ Division Manager □ Department Head □ Risk Managment
           Safety & Loss Control - Incident Investigation Report Form

Primary Type of Contact: (select all that apply)

    Absorption                                     Inhalation, Swallowing                       Slip, Trip, Fall
    Bodily Reaction                                Overexertion (lifting)                       Struck Against/Struck By
    Caught In, Under or Between                    Repetitive Motion                            Temperature Extremes
    Exposure to, Contact with                      Rubbed or Abraded


     Causal Analysis (see Guide for Identifying Causal Factors and Corrective Actions)
                                                   Behaviors: (select all that apply)
    Authority to Operate Equipment                                     Mixing or combining of substances
    Awareness of Surroundings                                          Mobile Radio/Cell Phone Use
    Clothing (other than P.P.E.)                                       Need for Assistance
    Driver Actions                                                     Operating Speed
    Drugs or Alcohol                                                   P.P.E
    Equipment Operator Actions                                         Placement or Storage
   Failure to Secure                                                   Positioning for Task
    Grip or Hold                                                       Safe work practices or rules
    Horseplay or Fighting                                              Safety Devices
    Intentional Act/Sabotage                                           Servicing Equipment in Operation
    Lifting, pushing, or pulling                                       Use of Equipment
    Loading or stacking                                                Use of equipment or tools
    Lockout / Tagout                                                   Warning or Instruction

                                             Conditions: (select all that apply)
    Environmental Conditions (gases, dusts, smoke, fumes)       Noise
    Equipment Failure                                                  Protective Equipment
    Exposure to cold temperatures                                      Radiation
    Exposure to hot Temperatures                                       Tools/equipment availability
    Fire / Explosion                                                   Ventilation
    Guards or Barriers                                                 Vibration
    Housekeeping                                                       Visibility
    Illumination                                                       Walking or Working surface
    Labeling                                                           Warning Systems
    New or Modified Equipment                                          Weather Conditions
    New or Modified Procedure                                          Workspace Conditions (congested or restricted access/egress)

Write a brief description for each box checked above in the Causal Analysis section (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 2 of 3

      Distribution List: □ Employee Incident File □ Division Manager □ Department Head □ Risk Managment
           Safety & Loss Control - Incident Investigation Report Form

Basic or Root Causes: (select all that apply)
   Abuse or misuse                                                     Physical Capability
    Employee knowledge                                                  Physical Stress or fatigue
    Employee Skill                                                      Procurement/Purchasing
    Engineering or Design                                              Risk Assessment
    Inspections                                                         Supervision or Leadership
    Maintenance                                                         Tools, Equipment, or Materials
    Management Systems                                                  Training
    Mental Stress or Fatigue                                            Retraining
    Mental or Psychological Capability                                  Wear and Tear
    Motivation                                                          Work Standards or Procedures

Write a brief description for each box checked above (i.e. Training – The department has not provided training to employee on
slip/trip and fall for more than a year.)




     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.                                      John Doe           7/25/08
         2. Ensure to include Slip/Trip and Fall training as part of an annual              Jane Doe           7/25/08
             refresher tailgate meeting.)




     Investigation Review and Approval
Department Safety Representative/Investigator Signature                                        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 3 of 3

      Distribution List: □ Employee Incident File □ Division Manager □ Department Head □ Risk Managment

				
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Jun Wang Jun Wang Dr
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