Fill and Sign the Incident Investigation Form 22993912

ACCIDENT / INCIDENT INVESTIGATION REPORT FORM Employee Name: _______________________________________ Dept: _________________________ Date & Time Accident/Incident Reported: _____ / _____ / _____ @ ______: ______ AM / PM MM DD YY Date & Time Accident/Incident Occurred: _____ / _____ / _____ @ ______: ______ AM / PM MM DD YY Location of Accident/Incident: ___________________________________________________________ Vehicle Involved: No Yes ______________________ __________________________ Vehicle ID Number Police Report: Photos: No No Yes Date of Last Vehicle Inspection Yes # ________________________ Name of HR Representative Notified: _____________________________ Supervisor’s Report of Accident/Incident Describe in Detail What Happened: ________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Why Did the Incident/Accident Occur? _____________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Nature of Injury, Injury Type and Part of Body Affected: ______________________________________ Contributing Factors: Environmental (Noise, Vapors, Light, Heat, Critters, etc…) Design (Workplace Layout, Design of Tools and Equipment) System & Procedures (Lack of or Inappropriate Systems and Procedures) Human Behavior Comments: ___________________________________________________________________________ How was the employee trained for performing this job task? _____________________________ ______________________________________________________________________________ ______________________________________________________________________________ What is the safety procedure for this job? ____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What will be done in the interim and in the future to prevent this type of Incident/Accident? ___________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please check below what is applicable: I have reviewed the employee’s statement and interviewed witnesses listed in the employee’s report. I have discussed this completed report with the employee before turning it into the Department Head. Date: ______________________ I have not discussed this completed report with the employee before turning it into the Department Director for the following reason: _________________________________________________________ I have informed the employee that this accident/incident may be reviewed by the Accident Review Committee. _____________________________________________ ________________________ Reporting Supervisor’s Signature Date _________________________________________________ __________________________ Department Director’s Signature Date Employee’s Report of Accident/Incident The purpose of this report is to help us prevent future accidents/incidents from occurring and may be used by the Accident Review Committee. Date & Time Accident/Incident Occurred: _____ / _____ / _____ @ ______: ______ AM / PM MM DD YY Who else was with you or witnessed the accident/incident when it occurred? ________________ ______________________________________________________________________________ What were you doing at the time the accident/incident occurred? _________________________ ______________________________________________________________________________ ______________________________________________________________________________ What happened? ________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ How do you think the accident/incident occurred? _____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Nature of Injury, Injury Type and Part of Body Affected: ______________________________________ _____________________________________________________________________________________ How were you trained for performing this job task? ____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What is the safety procedure for this job? ____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What Personal Protective Equipment (PPE) were you wearing at the time of the accident/incident? ______________________________________________________________ ______________________________________________________________________________ I did/will seek medical treatment for this accident/incident. I did not/will not seek medical treatment for this accident/incident at this time. If I decide to seek treatment at a later date for this accident/incident, I understand that I need to call 1-877676-3890 for authorization. I understand that if I have sustained an injury/illness due to this accident/incident, I am required to report it immediately to my supervisor so that I can be treated at a facility authorized by the City’s Workers’ Compensation insurance. I further understand that I am responsible for reporting injuries/illnesses to Workers’ Compensation by calling 1-877-676-3890. __________________________________________________ Employee’s Signature __________________________ Date Employee’s Printed Name: ______________________________________________________ Witness’s Report of Accident/Incident Date & Time Accident/Incident Occurred: _____ / _____ / _____ @ ______: ______ AM / PM MM DD YY Location of Accident/Incident: ___________________________________________________________ Vehicle(s) Involved: No Yes _____________________________________________________ Description of vehicle(s) Please provide any information you have that may be helpful in the investigation of the incident/accident you witnessed. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Printed Name: ________________________________________________________________ Contact Information: ___________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________ Signature ________________________ Date