Accident Investigation Report (e371)



49949101143000ACCIDENT/INJURY INVESTIGATION REPORTSection I of this form must be completed within 24 hours of all occupational injuries, illnesses, or accidents involving ER/St James Mercy Hospital’s temporary or full-time employees and submitted to Human Resources Retain this form in the branch OSHA/Workers' Compensation file for five years from the date of the incident or five years after the workers' compensation claim is closed, whichever is longer. Form is equivalent to OSHA's form 301.Section I – ACCIDENT/INJURY INVESTIGATION REPORTCompleted by Employee with Manager/Supervisor:DIRECTIONS:If employee needs URGENT medical care, please obtain the written statement as soon as possible following treatment. Please write clearly. FORM MUST CONTAIN THE EMPLOYEE’S SIGNATURE.EMPLOYEE Full NAME: ______Injured employee’s job title: ______Department: ___________EMPLOYEE Address: ___________________________________________________________________________________City: _____________________________________________________________ State_______ Zip____________________Date of Birth____/____/_____ Date Hired____/____/_____ Male____ Female______DATE OF INJURY: __________________ TIME EMPLOYEE STARTED WORK________________ APPROXIMATE TIME OF INJURY: ______Was the Employee treated in an Emergency room? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please describe the type of treatment received: __________ Name of facility where it was provided: Physician or other health care professional_____Was Employee hospitalized overnight as an in-patient? FORMCHECKBOX Yes FORMCHECKBOX NoDid the injury/illness result in lost time or restricted duty? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please describe: __________Section I - ACCIDENT/INJURY INVESTIGATION REPORT cont’Completed by Employee with Manager/Supervisor:WHEN DID YOU FIRST REPORT THIS, AND TO WHOM WAS IT REPORTED? __________IF YOU DID NOT REPORT THIS IMMEDIATELY WHEN IT OCCURRED, PLEASE EXPLAIN WHY: __________WHAT WAS THE EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURRED? __________WHAT HAPPENED? DESCRIBE EXACTLY HOW THIS INJURY OCCURRED:____________________WHAT WAS THE INJURY OR ILLNESS ( tell us the part of the body that was affected and how it was affected; be more specific than "hurt", "pain" or "sore"):__________What Object or substance directly harmed the employee?___________________________________________________________________________________MARK THE AREA ON THE ILLUSTRATION BELOW WHERE YOU AREHAVING THE SYMPTOMS YOU DESCRIBED ON THE INJURY REPORT FORMCHECKBOX PALM SIDE FORMCHECKBOX TOP OF FOOT FORMCHECKBOX BACK SIDE FORMCHECKBOX BOTTOM OF FOOT*Note: Please attach photographs, drawings, statements, and any additional data to report.Date: Employee Signature (Required): _____ Section I - ACCIDENT/INJURY INVESTIGATION REPORT cont’Completed by Employee with Manager/Supervisor:WAS A SAFETY DEVICE REQUIRED? FORMCHECKBOX YES FORMCHECKBOX NOWERE YOU TRAINED PROPERLY ON HOW TO USE THE SAFETY DEVICE? FORMCHECKBOX YES FORMCHECKBOX NODID YOU USE THE SAFETY DEVICE? FORMCHECKBOX YES FORMCHECKBOX NOIF APPLICABLE, WHAT SAFETY DEVICE WAS REQUIRED AND/OR USED? __________HAVE YOU EVER EXPERIENCED THE SAME OR SIMILAR SYMPTOMS DESCRIBED ABOVE, OR HAD A PRIOR INJURY TO THE SAME PART OF YOUR BODY? FORMCHECKBOX YES FORMCHECKBOX NOThis information allows us to determine your pre-existing status. This does not disqualify you from being entitled to care for any current injury or any aggravation to an underlying pre-existing condition. It is in your best interest to provide this information at the time of injury.IF YES, PLEASE EXPLAIN: _______________WHO WAS YOUR MEDICAL TREATMENT PROVIDER FOR THIS PRIOR CONDITION/INJURY? _______________APPROXIMATELY WHEN DID THIS PRIOR TREATMENT OR INJURY TAKE PLACE? _______________ I understand that this statement will be considered part of the investigation process and that I may be called upon to testify or provide written or verbal clarifying statements. The statement I have provided is an accurate account of the case to the best of my knowledge.Date: Employee Signature (Required): _____Section I - ACCIDENT/INJURY INVESTIGATION REPORT cont’Completed by Employee with Manager/Supervisor:Contributing FactorsCheck all contributing factors to the accident in the boxes below.Injury and Property Damage FORMCHECKBOX Distraction FORMCHECKBOX Failure to secure (locking, tightening, closing) FORMCHECKBOX Failure to use personal protective equipment FORMCHECKBOX Failure to warn (signs, barricades, alarms) FORMCHECKBOX Horseplay FORMCHECKBOX Improper activation FORMCHECKBOX Improper body mechanics FORMCHECKBOX Improper loading FORMCHECKBOX Improper placement FORMCHECKBOX Improper position for task FORMCHECKBOX Improper safety equipment FORMCHECKBOX Making safety devices inoperable FORMCHECKBOX Operating equipment without authority FORMCHECKBOX Operating at improper speed (hurrying, speeding) FORMCHECKBOX Removing safety devices FORMCHECKBOX Servicing equipment in operation/no lockout FORMCHECKBOX Unsafe driving FORMCHECKBOX Using defective equipment FORMCHECKBOX Using equipment improperly FORMCHECKBOX Under influence of drugs or alcohol FORMCHECKBOX Confined space entry (tanks or vessels) FORMCHECKBOX Congested or restricted area/activity FORMCHECKBOX Defective tools, equipment, or materials FORMCHECKBOX Excessive noise FORMCHECKBOX Explosion FORMCHECKBOX Fire FORMCHECKBOX Hazardous environmental conditions (spills, gases, dusts, smokes, fumes, vapors) FORMCHECKBOX Hazardous personal attire FORMCHECKBOX High or low temperature exposure FORMCHECKBOX Icy conditions FORMCHECKBOX Inadequate guards or barriers FORMCHECKBOX Inadequate lighting FORMCHECKBOX Inadequate protective equipment FORMCHECKBOX Inadequate ventilation FORMCHECKBOX Inadequate warning system (alarms, barricades, signs) FORMCHECKBOX Poor housekeeping; disorder FORMCHECKBOX Projecting hazard (pole, angle iron, etc.) FORMCHECKBOX Pinch point (gears, pulleys, belts, etc.) FORMCHECKBOX Road conditions FORMCHECKBOX Safety device inoperable FORMCHECKBOX Slippery conditions FORMCHECKBOX Hazardous storage/stacking FORMCHECKBOX Other (explain): FORMTEXT ?????Vehicle Accident FORMCHECKBOX Following too closely FORMCHECKBOX Improper turning FORMCHECKBOX Improper backing FORMCHECKBOX Improper lane change FORMCHECKBOX No/improper pre-trip FORMCHECKBOX Left of center FORMCHECKBOX Failure to secure equipment FORMCHECKBOX Improper use of mirrors FORMCHECKBOX Improper use of turn signals FORMCHECKBOX Improper use of lights FORMCHECKBOX Improper use of horn FORMCHECKBOX Improper use of emergency equipment FORMCHECKBOX Misjudged clearance FORMCHECKBOX Failed to yield right of way FORMCHECKBOX Alcohol - under influence FORMCHECKBOX Drugs - under influence FORMCHECKBOX Disregarding traffic signals/signs FORMCHECKBOX Unsafe speed for conditions FORMCHECKBOX Improper passing FORMCHECKBOX Obstructing traffic FORMCHECKBOX Improper load FORMCHECKBOX Failure to use safety equipment FORMCHECKBOX Improper parking FORMCHECKBOX Defective brakes FORMCHECKBOX Worn/smooth tires FORMCHECKBOX Defective lights (vehicle) FORMCHECKBOX Inadequate lighting (roadway) FORMCHECKBOX Defective windshield wipers FORMCHECKBOX Defective steering mechanism FORMCHECKBOX Road construction FORMCHECKBOX Loose road surface materials FORMCHECKBOX Holes/ruts in road FORMCHECKBOX Standing water FORMCHECKBOX Defective equipment tools FORMCHECKBOX Icy road conditions FORMCHECKBOX Wet road conditions FORMCHECKBOX Inclement weather FORMCHECKBOX Parked/stopped vehicle FORMCHECKBOX Overloaded vehicle FORMCHECKBOX Obstruction to view (signs, trees, buildings., etc.) FORMCHECKBOX Glare FORMCHECKBOX Fog FORMCHECKBOX Smoke FORMCHECKBOX Other (explain): FORMTEXT ?????Provide details for all contributing factors checked above. FORMTEXT ?????Section II – ACCIDENT/INJURY INVESTIGATION REPORT Completed by witnesses and/or co-workers:CO-EMPLOYEE/WITNESS STATEMENT DIRECTIONS:Please write clearly. FORM MUST CONTAIN THE SIGNATURE OF THE PARTY SUPPLYING THE STATEMENT. Make copies if additional statements are required.STATEMENT REGARDING: _____ (name of injured employee)WITNESS NAME: _____WITNESS JOB TITLE: _____WHAT IS YOUR KNOWLEDGE REGARDING THIS INJURY: ________________________________________(USE BACK OF FORM IF NECESSARY)PLEASE LIST ANY OTHER WITNESSES OR INDIVIDUALS THAT MAY HAVE INFORMATION RELATIVE TO THIS INVESTIGATION: _______________I understand that this statement will be considered part of the official investigation and that I may be called upon to testify or provide written or verbal clarifying statements. The statement I have provided is an accurate account of the case to the best of my knowledge.Date: Signature (Required): _____Phone: Home Address: _____Section III – ACCIDENT/INJURY INVESTIGATION REPORT Completed by Employee with Manager/Supervisor:Root CausesCheck all applicable causal factors (root cause) that, if corrected, would prevent recurrence of the same or similar injury/illness, accident, or near miss.Personal Factors FORMCHECKBOX Improper work habits FORMCHECKBOX Lack of knowledge FORMCHECKBOX Lack of skill FORMCHECKBOX Physical limitations FORMCHECKBOX Pre-existing conditionJob Factors FORMCHECKBOX Abuse or misuse FORMCHECKBOX Improper equipment/tool design FORMCHECKBOX Inadequate engineering FORMCHECKBOX Inadequate leadership/supervision FORMCHECKBOX Inadequate maintenance FORMCHECKBOX Inadequate purchasing standards FORMCHECKBOX Inadequate training FORMCHECKBOX Inadequate work procedures FORMCHECKBOX Overtime FORMCHECKBOX Promotional (sales) FORMCHECKBOX Unusual work load FORMCHECKBOX Wear and tear FORMCHECKBOX Not employee’s regular occupation FORMCHECKBOX Not employee’s regular work hoursProvide details for all root causes checked above. FORMTEXT ?????Corrective Action PlanCheck all actions needed to eliminate recurrence of the same or similar accident.Change ProceduresChange BehaviorMake Work Improvements FORMCHECKBOX Modify housekeeping procedures FORMCHECKBOX Develop safer work procedures FORMCHECKBOX Eliminate unsafe activity procedures FORMCHECKBOX Communicate job procedures FORMCHECKBOX Review employee skills relating to job FORMCHECKBOX Review/improve maintenance of tools/equipment FORMCHECKBOX Redesign work process FORMCHECKBOX Require additional training/orientation FORMCHECKBOX Other FORMTEXT ????? FORMCHECKBOX Prevent/correct employees bypassing safety devices FORMCHECKBOX Prevent/correct operation of unsafe equipment FORMCHECKBOX Act to enforce use of protective equipment FORMCHECKBOX Act to prevent/correct unsafe speed or improper operation FORMCHECKBOX Act to prevent/correct employee doing unsafe work FORMCHECKBOX Correct the disregard of unsafe work conditions FORMCHECKBOX Enforce/use correct safety procedure FORMCHECKBOX Act to prevent on premise intoxication/other FORMCHECKBOX Take action to address general health problem FORMCHECKBOX Take disciplinary action FORMCHECKBOX Other FORMTEXT ????? FORMCHECKBOX Modify design of work station FORMCHECKBOX Modify lighting FORMCHECKBOX Modify ventilation FORMCHECKBOX Modify flow of materials FORMCHECKBOX Provide better tools and equipment FORMCHECKBOX Replace defective equipment FORMCHECKBOX Safeguard against failure of safety devices FORMCHECKBOX Prevent/alleviate unguarded hazard FORMCHECKBOX Prevent/alleviate crowded conditions FORMCHECKBOX Prevent/alleviate slippery/wet conditions FORMCHECKBOX Take actions to prevent blind corners FORMCHECKBOX Prevent/alleviate unsafe conditions/acts FORMCHECKBOX Other FORMTEXT ?????Provide details for all corrective actions checked above.No.Description of Corrective ActionAssigned ToCompletion Date1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Investigating Supervisor's SignatureDate: FORMTEXT ?????RiskIf this accident went uncorrected and happened again, how severe would it be? FORMCHECKBOX Major FORMCHECKBOX Serious FORMCHECKBOX Minor If this accident went uncorrected and happened again, what is the probability it would reoccur? FORMCHECKBOX Frequent FORMCHECKBOX Occasional FORMCHECKBOX SeldomInvestigation Conducted by:Name FORMTEXT ?????Title FORMTEXT ?????SignatureDate FORMTEXT ?????Arrange meeting with Accident Investigation Committee for further review: ? ................
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