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Case Number             Employee Number       Regular Job Title

Employee Last Name   First Name             Age                 Gender:   Male Female

Employee Address     Line 2     City   State: Choose One ALAK AZCA COCT DEFL GAHI IDIN IAKS LAIN MDMA MNMS MOMT NENJ NMNY NCND OHOR PARI SCSD TNTX UTVT WAWI WVWY   Zip Code     +4

Employee Status Choose one Vendor Visitor Employee/Directly Supervised Contractor       Contracting Company             Regular Department      

Regular Job Group Choose one Office/Administration Maintenance Craft Support Services Production Operations      Shift Hours Working: Choose One N/A Yes No

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Location

Location Address     Address 2     City   State Choose One ALAK AZCA COCT DEFL GAHI IDIN IAKS LAIN MDMA MNMS MOMT NENJ NMNY NCND OHOR PARI SCSD TNTX UTVT WAWI WVWY   Zip   +4

Incident Time :     Date of Incident             Date Reported             Date Lost Time Began

Date of Restricted Activity             Date Permanently Transferred     Date Returned to Full Duty  

Nature of Injury     Injured Body Part         Body Side Indicator   Left Right Both

Physician Type       Physician's Last Name       Physician's First Name

Physician Address     Line2     Physician City   State Choose One ALAK AZCA COCT DEFL GAHI IDIN IAKS LAIN MDMA MNMS MOMT NENJ NMNY NCND OHOR PARI SCSD TNTX UTVT WAWI WVWY   Zip   +4

Hospital Name

Hospital Address     Line 2     City   State Choose One ALAK AZCA COCT DEFL GAHI IDIN IAKS LAIN MDMA MNMS MOMT NENJ NMNY NCND OHOR PARI SCSD TNTX UTVT WAWI WVWY   Zip   +4

Case Type Choose One Vendor Visitor Restricted Work Lost Work Day Injury - Free Event         Was this a Major Incident Yes No         Major Incident Type Choose One Chemical Hazard Electrical Hazard Fall Hazard Fire Hazard Molten Metal Hazard Other Lockout/tagout/verify Production Equip-Machine Guarding Confined Space/Excavation Health Hazard Mobile Equipment Fixed Rail Crane Mobile Equipment Fixed Rail Train Earth Moving Mobile Equipment Public Equipment Failure Airborne Explosion Hazard (Powder, Flammable gas) Unplanned Shutdown(power interruption, evacuation High Pressure Rupture/Release/Explosion        

Other Results Choose One Loss of Consiousness Temporary Job Transfer Permanent Job Transfer Employee Termination Permanent Restriction Permanent Total Disability

 

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Department         Exact Location of Event         On-Site? Yes No

Job Position at Time of Event             Number of Years in Job/Position             Month in Job/Position

Incident Agent             Contact Agent             Process Description    

Specific Area/Equipment   General Job/Task         Task Being Performed at Time of Event  

Production Loss $ amount         Property Damage $ amount

Severity Potential Choose One Catastrophic (fatality) Critical Marginal Negligible                 Negligible Potential Choose One Impossible Improbable Remote Occasional Probable Occasional

What Occurred? (Who, What, Where & When)

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Type of Incident Choose One Struck by Struck against Contacted by Contact with Trapped in Caught on Caught between Same level fall Different level fall Strain overexertion Exposure         Ergonomically Related Yes No        

If Ergonomically Related is YES Choose One Any momentary or sustained forces or weights (pushing, lifting, holding, supporting, etc. Repetition or continuous tasks Awkward posture or position (bending, reaching, twisting, elevated arms, bent writst, etc. Vibration in hand/arms, whole body, etc. (from air tools, jackhammers, nutrunners, grinders, machining, hamering, pounding, etc. also mobile equipment operation. Pinch type grip or fine detail precision. Were confusing/illogical controls, equipment, or layout or human error a contribution factor? (Cognitive/mental design) Were there any other ergonomics risk factors present (not already mentioned above) that would make this an ergonomics injury?

Please quantify and explain ALL "Yes" answers

Incident Analysis and Corrections to Prevent Recurrence

If Fatality, Date of Death                 Potential for Fatality High Medium Low     Contributing Actions Choose One Operating w/o training Failure to make secure Operating at unsafe speed Inadequate warning/signal Nullified safety device Used defective equipment Used equipment unsafely Used wrong tool/equipment

Cause of Contributing Actions Choose One Unaware of job hazards Inattention to hazard Unaware of safe method Low level job skill Tried to gain or save time Tried to avoid extra effort Tried to avoid discomfort Influence of emotions Influence of fatigue Influence of intoxicant/drugs Defective vision/hearing Influence of illness Other factors Unknown factors     Contributing Conditions Choose One Inadequate guard/safety device Hazardous attire Inadequate warning system Fire or explosion hazard Unsecured against movement Poor housekeeping Protuding object hazard Close clearance/congestion Hazardous arrangement/storage Defective tools equipment Atmospheric conditions Illumination/noise hazard Other unsafe condition No unsafe condition     Cause of Contributing Conditions Choose One Caused by employee Caused by another employee Defective via abuse/misuse Defective via abuse/misuse Inadequate safety inspection Inadequate housekeeping/clean-up Faulty design/construction Outside contractor Inadequate preventative maintenance Purchasing practice Deteriorating exposure Management acceptance Other source cause Unknown source cause    

Supervisor Last Name   First Name             Supervisor Employee Number       Date Form Completed

Participants in Investigation 1. 2. 3. 4.

Submitted By Last Name   First Name             Submitted By

Corporate EHS Manager Last Name   First Name             EHS Submit Date