Attachment 10 June 23 2003 by jakianur

VIEWS: 3 PAGES: 2

									ATTACHMENT 10


     Incident No: ________________

                SHE INCIDENT INTERVIEW NOTES / CHECKLIST

    Incident Description:                                    Incident Date / Time:     Reference #



    Interview date:               Interview Time:                       Time ended:



    Name / Tel. #                 Job Title:                            Supervisor’s Name / Tel. #



    1. What were you doing before the incident happened?



    2. Where were you at the time of the incident?



    3. What were the working conditions like (workplace and weather?)



    Please tell me about what happened (what you saw and did, who else was involved, approximate
    times, how long things went on for)




    4. Types of equipment involved?


    5. Locations of: anyone involved, hurt, equipment, materials?


    6. Positions of: anyone involved, anyone hurt, equipment, materials?



     SISE/006/230603

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               SHE INCIDENT INTERVIEW NOTES / CHECKLIST
                                              (continued)

7. Operating conditions before and after?


8. What other people were doing?


9. Names of people involved / hurt?


10. Emergency response actions?


11. Anything moved, repositioned? (to control situation / emergency response)


12. Job preparation / training?


13. Who else might have valuable information?


14. Any similar incidents before?


15. Is there anything else you would like to mention, no matter how unimportant it seems?


16. Do you have suggestions for possible improvements?


                Please contact me if you think of anything else that might be important.
interviewee:                                         interviewer:

_____________         ___________     ________       _____________        ___________       ________
     Name              Signature       Date               Name             Signature         Date

Follow up notes:




 SISE/006/230603

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