Accident Investigation

Objective: To summarize the accident, determine root causes, and provide recommendations and resources to prevent reoccurrence.

Investigation

Conducted By

Department
Time of Investigation
Date of Investigation
Campus Phone
Campus E-mail
H. R. Notified? / ( ) Yes ( ) No Human Resources 7423

Personal Data – Injured Worker

Name

Address
Telephone / Campus ______Home ______
Age
Job Title
Job Classification / ( ) Faculty ( ) Student worker ( ) Exempt ( ) Classified
Hire Date
Time in Position
Specific Location
Date/Time of Incident / _____/_____/______:_____ AM/PM
Time work started / _____:_____ AM / PM
Regular Job Duty? / ( ) Yes ( ) No
Specific Task Performed at Time of the Incident
Activity performed prior to incident
Type of Injury
(i.e., fracture, strain, burn, etc.) / ( ) Amputation ( ) Burn ( ) Concussion ( ) Contusion, Crush
( ) Cut/Puncture ( ) Dermatitis ( ) Dislocation ( ) Fracture
( ) Freezing/Frostbite ( ) Hernia ( ) Inflammation ( ) Scratch
( ) Sprain/Strain ( ) Other ( ) Unknown
Body part affected
Extent of injury
Object that directly injured employee
Type of accident / ( ) Fall – same level ( ) Fall – elevated ( ) Overexertion
( ) Caught in, under or between ( ) Struck by ( ) Struck against
( ) Electrical contact ( ) Caustic contact ( ) Abrasion
( ) Motor vehicle ( ) Public Transportation ( ) Chemical
( ) Other – describe - ______

Result of Incident

/ ( ) Non-medical ( ) First Aid ( ) Medical ( ) Property Damage

Witness #1

Name

Address
Telephone
Job Title
Hire Date
Time in Position
Task Performed at Time of the Incident
Proximity to Incident
Witness: / ( ) Saw the actual accident ( ) Heard the accident ( ) Saw immediate result of accident

Witness’s Account of Incident

Witness #2

Name

Address
Telephone
Job Title
Hire Date
Time in Position
Task Performed at Time of the Incident
Proximity to Incident
Witness: / ( ) Saw the actual accident ( ) Heard the accident ( ) Saw immediate result of accident

Witness’s Account of Incident

Incident Analysis

Incident Description
Attach sketches, diagrams, or photos as appropriate
Causal Factors
Equipment & Tools / Yes / No / Comments
Operating equipment without authority
Using equipment improperly
Operating at improper speed
Improper loading or overloading
Servicing equipment in operation
Hazardous condition not recognized
Hazardous condition not reported
Inadequate guards or barriers
Defective tools or equipment
Inadequate tools/equipment
Excessive wear and tear on equipment
Inadequate maintenance
Safety devices rendered inoperable
Safety devices removed
Correct equipment not used
Correct equipment unavailable
Correct tool not used
Correct tools unavailable
MSDSs available
Other (not listed above)
Other (not listed above)
Personal Protective Equipment (PPE) / Yes / No / Comments
Failure to use PPE properly
Failure to use required PPE
PPE not available
Improper/inadequate PPE
Employee not trained in PPE
PPE not specified for task
Emergency Equipment:
A.  Not Specified
B.  Not Available
C.  Not Used
D.  Malfunctioned
Lockout – Tagout followed
Other (not listed above)
Other (not listed above)

Training

/ Yes / No / Comments
Employee trained in task procedures
Date of last training in task
Describe Prior Training Received for Task Performed
Lack of skill or experience
Unsafe/Unauthorized Behavior
Job procedure adequate
Deviation of job procedure
Job procedure too difficult
Other (not listed above)
Other (not listed above)
Environment / Yes / No / Comments
Housekeeping at task area acceptable
Adverse physical hazards – noise, or temperature
Airborne dust, mists, vapors
Chemical hazards
Ergonomic hazards
Adequate ventilation
Adequate lighting
Weather-related
Location of task in a hazardous area
Hazardous condition not recognized
Hazardous condition not reported
Hazardous condition not detected
Co-workers contributed to hazard
Co-workers not aware of hazards
Employee did not belong in area
Fire or explosion hazard
Other (not listed above)
Other (not listed above)

Safety System

/ Yes / No / Comments
Pre-job process review conducted with employee
Pre-job hazard review conducted with employee
Supervisor had visited the job before the accident
Ergonomic hazards present
Unsafe/Unauthorized Behavior
Physical or mental stress
Substandard housekeeping during task
Drugs/alcohol suspected
Other (not listed above)
Other (not listed above)

Other Concerns

/ Yes / No / Comments
Employee work a second job
Pre-existing injuries that may have contributed to incident?
Return to work process needed
Transitional work process needed
Other (not listed above)

Summary of Incident

Summarize the incident

(photos or sketches may be attached if needed)

Analysis of Incident

Describe conditions that led to or contributed to the incident

(environmental, tools, equipment, behavior, work history, etc.)

Recommended Corrective Actions to Prevent Recurrence of Incident

Describe any controls and/or corrective procedures that can prevent recurrence of a repeat or similar incident on campus.

Accident Investigation

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