Root Cause Investigation Form

							                                            SARASOTA COUNTY GOVERNMENT
                                        WORKPLACE ACCIDENT INVESTIGATION REPORT
PART A
Occ Health Case Number        Incident Date               Date Incident Reported       Day of week of incident        Supervisor Name


Name of Injured                                                                        Business Center and Unit

Length of Employment         Employee’s Usual Job                         Job At Time of Accident                     Length of Time in Current Position


Specific Location of the Accident                                                   Physical Description of Injury (i.e. Cut Finger, Twisted Ankle, etc.)


Others Injured/Involved/Witness in Same Accident        Phone numbers of others




PART B
Describe, In Detail, How the Accident Occurred:




PART C
Causal Factors and Corrective Actions. Check ALL that apply. Events and conditions that contributed to the accident.
EQUIPMENT - Root Causes                                                            EQUIPMENT – Corrective Action             Assigned To
  Electrical Hazard    Equipment Defective                 Steps, Stairs
  Welding              Safety Device                       Boardwalk, Sidewalk
  Heavy Equipment   Inoperable                             Ladders
  Chemical Hazard      Equip. Inadequate                   Other List
  Hand Tools           PPE
MANAGEMENT - Root Causes                                                           MANAGEMENT –
                                                                                   Corrective Actions                        Assigned To
  No Training Providing     Policies and                    System Failure
  No JSAs                Procedures                         PM not Performed
  Equipment unavailable     Improper PPE                    Staffing Inadequate
  Lack of Accountability Given                              Other List
  No Inspections Done
ENVIRONMENT - Root Causes                                                          ENVIRONMENT –
                                                                                   Corrective Action                         Assigned To
  Fire Hazard         Tight Working Area                   Poor Lighting
  Snake               Uneven Ground                        Poor Housekeeping
  Spider              Poor Footing                         Weather
  Insects             Release-Chemical                     Other List
BEHAVIOR/PEOPLE - Root Causes                                                      PEOPLE – Corrective Actions               Assigned To
  No Lockout Used   Safety Device Bypassed                   Equipment Used
  Unsafe Act        Distraction/Haste                     Incorrectly
  PPE not worn      Safety Rules ignored                     Other List
  Violence          Unaware of surroundings
ERGONOMIC - Root Causes                                                            ERGONOMIC –
                                                                                   Corrective Actions                        Assigned To
  Repetitive Twisting of Wrists               Shoulders too high/low
  Repetitive Twisting at Waist                Body not in neutral position
  Improper Positioning of Head                Horizontal Distance too great
  Improper Tool                               Other List
  Vibration

                                                           Accident Investigation conducted by:
Name(s):                                                                           Date:

Provide a copy of this form to the Business Unit Safety Committee and to Safety and Risk Management within 2 days of the accident. Fax 861-5966
e-mail risk@scgov.net




DISTRIBUTION: COPIES TO: Safety and Risk Management, Business Unit Safety Committee
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