CCI First Report of Incident



|Incident Report | |

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|Project Name:________________________ | |

|Project Number:_______________________ | |

| First Report of Incident |Rev -10-2015 |

|Project |Date of Incident: |Time: AM or PM |Day of Week |

|Data | | | |

| |Date of Report: |Time of Report: AM or PM |

| |Project Manager/Resident Engineer: |

| |Superintendent /Supervisor: |

| |Drug Screen (s) Administered: Y or N |If Yes, List Employees: |

| |Are There Any Witnesses? Y or N |If Yes, List Employees: |See Page 5 for Witness |

| | | |Instructions |

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| Personal|Employee Name: |SS#: |Sex: M - F |

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|Data | | | |

| |Employee Home | |Date of Birth: |

| |Address: | | |

| | | |Phone: |

| |Occupation/Title: |Years Experience: |Date of Hire: |Sub? Y or N |

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|Personal |Onsite First Aid Given: Y or N |If Yes, by Whom: |

|Injury –| | |

|WC ( | | |

|N/A | | |

| |Offsite Medical Treatment: Y or N |If Yes, Treating Facility: |

| |Date Treatment Given: |Treating Facility Phone: |

| |Has employee returned to work? Y or N |If Yes, When? If No, Probable length of disability? |

| |Shade the Specific Body Part (s) Injured: |Injury tracking (See Page 6 for Instructions) |

| |[pic] |Injury Type: |Part of Body Injured: |

| | |Nature of Injury: |Type of Treatment: |

| | |Description of Injury: |

| | |List any doctor restrictions: |# Days: |

| | |List PPE worn at the time of the incident: |

| | |Incident Designation: |

| | |First Aid Only |Restricted Work |

| | |Non Recordable – Medical Treatment|Recordable - Lost Time |

| | |Recordable – Medical Treatment |Claim Denied |

|Supplemental Injury Information (Enter Corresponding Letter(s) for Injury/Illness Incidents Only) |

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|If JTS employee injured |

|Employee Name: ____________________________ Employee Number: ___________________________ |

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|If non-JTS employee injured |

|Employee Name: ____________________________ Company: ____________________________________ |

|Contractor Contact: ________________________ Phone number: ________________________________ |

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|Injury Type: |

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|a. Allergic Reaction |

|m. Electric Shock |

|x. Multiple (Specify) |

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|b. Amputation |

|n. Foreign Body in eye |

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|c. Asphyxia |

|o. Fracture |

|y. Muscle Spasms |

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|d. Bruise/Contusion/Abrasion |

|p. Freezing/Frost Bite |

|z. Other (Specify) |

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|e. Burn (Chemical) |

|q. Headache |

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|f. Burn/Scald (Heat) |

|r. Hearing Loss |

|aa. Poisoning (Systemic) |

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|g. Cancer |

|s. Heat Exhaustion |

|bb. Puncture |

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|h. Carpal Tunnel |

|t. Hernia |

|cc. Radiation Effects |

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|i. Concussion |

|u. Infection |

|dd. Strain/Sprain |

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|j. Cut/Laceration |

|v. Irritation to eye |

|ee. Tendonitits |

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|k. Dermatitis |

|w. Ligament Damage |

|ff. Wrist Pain |

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|l. Dislocation |

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|Part of Body Injured: |

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|a. Abdomen |

|o. Hand(s) |

|aa. Neck |

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|b. Ankle(s) |

|p. Head |

|bb. Nervous System |

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|c. Arms (multiple) |

|q. Hip(s) |

|cc. Nose |

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|d. Back |

|r. Kidney |

|dd. Other (Specify) |

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|e. Blood |

|s. Knee(s) |

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|f. Body System |

|t. Leg(s) |

|ee. Reproductive System |

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|g. Buttocks |

|u. Liver |

|ff. Shoulder(s) |

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|h. Chest/Ribs |

|v. Lower (Arms) |

|gg. Throat |

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|i. Ear(s) |

|w. Lower (Legs) |

|hh. Toe(s) |

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|j. Elbow(s) |

|x. Lung |

|ii. Upper (Arms) |

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|k. Eye(s) |

|y. Mind |

|jj. Upper (Legs) |

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|l. Face |

|z. Multiple (Specify) |

|kk. Wrists |

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|m. Finger(s) |

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|n. Foot/Feet |

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|Nature of Injury: |

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|a. Absorption |

|h. Inhalation |

|n. Overexertion |

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|b. Bite/Sting/Scratch |

|i. Lifting |

|o. Repeated Motion/Pressure |

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|c. Cardiovascular/Respiratory System |

|j. Mental Stress |

|p. Rubbed/Abraded |

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|Failure |

|k. Motor Vehicle Accident |

|q. Shock |

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|d. Caught In or Between |

|l. Multiple (Specify) |

|r. Struck Against |

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|e. Fall (from Elevation) |

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|s. Struck By |

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|f. Fall (Same Level) |

|m. Other (Specify) |

|t. Workplace Violence |

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|g. Ingestion |

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|Type of Treatment: |

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|a. Admission to hospital/medical facility |

|i. Nonprescription medication |

|r. Soaking Therapy – one treatment |

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|b. Application of bandages |

|j. None |

|s. Stitches/sutures |

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|c. Cold/heat compression – multiple |

|k. Observation |

|t. Tetanus |

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|treatment |

|l. Other (Specify) |

|u. Treatment for Infection |

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|d. Cold/heat compression - one |

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|v. Treatment for 2nd/3rd degree burns |

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|treatment |

|m. Prescription – multiple dose |

|w. Use of antiseptics – mult. treatment |

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|e. First-degree burn treatment |

|n. Prescription – single dose |

|x. Use of antiseptics – one treatment |

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|f. Heat Therapy – multiple treatment |

|o. Removal of Foreign bodies |

|y. Whirlpool bath therapy - multiple |

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|g. Heat Therapy – one treatment |

|p. Skin Removal |

|z. Whirlpool therapy – one treatment |

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|h. Multiple (Specify) |

|q. Soaking Therapy – multiple |

|aa. X-rays negative |

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|treatment |

|bb. X-rays positive |

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|ACCIDENTS RESULTING IN PROPERTY DAMAGE, SPILL, EQUIPMENT DAMAGE OR OTHER |

|Property |Describe Property Damaged: |

|Damage ( N/A| |

| |Property Owner: |Phone #: |

| |Property Owner Address: | |

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| |Estimated Amount: $ |Other Pertinent Info: |

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|SPILL or |Substance (attach SDS): |Estimated Qty: |

|release ( | | |

|N/A | | |

| |Location: |Phone #: |

| |Spill Response: | |

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| |Did spill/release move off property where work was performed? Y or N |

| |Spill/Release From: |Spill/Release To: |

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|Environmental/|Describe The Release or Emission & Location: |

|Permit Issue | |

|( N/A | |

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| |Substance & Estimated Quantity: |

| |Duration of Permit Exceedance: |Environmental Contacts Notified: Y or N |

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| Auto & |Unit Description: |Unit/Serial Number: |

|Equipment| | |

|DAMAGE | | |

|( N/A | | |

| |Rental: Y or N |If yes, Rental ID#: |

| |Rented From: | |Estimated |

| | | |Damage: |

| | | |(Attach any repair estimates) |

| |Rental Company Phone: | |

| |Did Operator/Driver obey all applicable safety rules or D.O.T. Motor Vehicle Laws? |

| |Y or N If NO, list exceptions: |

| |Did Authorities Respond (fire, police, ambulance, |Responding Authority: |

| |etc)? Y or N | |

| |Police Report #: | |

| | |Contact Person: |

| | |Phone: |

| |Was there Other Vehicle or Property Damage: Y or N |Owner’s Name & Phone #: |

| | |Driver’s Name (if different than above) & Phone #: |

| | |License NO. & State: |

| |For Auto Damage, Shade the Specific areas damaged: |

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|Descripti|To be completed for all incidents |

|on of | |

|Incident | |

| |Describe in detail the circumstances of the incident. Give a chronological sequence of events. If materials, equipment and/or vehicles were |

| |involved, start before they were brought to the incident scene and describe the who, what, where when, and how the incident happened in your words |

| |below (specifically detail who, what, where, when, how, and why you believe the incident happened): |

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|To be completed for all incidents |

|(Show position and any relative distances of employee(s), vehicle(s), equipment, pedestrians, property, etc., and indicate an arrow of direction for each if |

|travel or moving equipment was involved): |

|Diagram of Incident |

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|WITNESS STATEMENTS – FOR ALL INCIDNETS |

|Witness Statement: Attach Witness to applicable incidents |

|Witness Name: |Witness Name: |

|Witness Name: |Witness Name: |

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|Witness Name: |SS # - - |

|(Please Print) | |

|Witness Address: |Work Phone: |Home Phone: |

|Date and Time of incident: am/pm |List other Witnesses: |

|Supervisor Notified on Date and Time: am/pm | |

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|This is what happened (include who, what, where, when, how and why): |

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|Do you recall anything unusual or unexpected that happened? Yes or No If Yes Explain: |

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|Are there work conditions that contributed to this injury? Yes or No If Yes Explain: |

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|How would you prevent this incident from happening in the future? |

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|Please use and attach additional pages if necessary |Witness Signature: |Date: |

LESSONS LEARNED & CORRECTIVE ACTIONS TAKEN

FOR ALL INCIDENTS

|Lessons |Did the “Job Hazard Analysis” or “Task Hazard Analysis” discuss the potential for this incident, and the safe work procedures to be followed to |

|Learned |prevent it? YES or NO. Please attach a copy of applicable document(s) to support your findings. |

|To be | |

|completed | |

|for all | |

|incidents | |

| |What was the Root Cause(s) of the Incident? |

| |Contributing Factor(s) to the Incident: (weather, lighting, traffic control plan, communication of hazards, etc.) |

| |Corrective Action(s)That Were Taken to Prevent Reoccurrence: |

|Participants of in the Incident Analysis |Management Review |

|Name/Title or Trade |Date |Name |Date |

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|Employee | | | |

|Signature: | | | |

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|Employee | | | |

|Signature: | | | |

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Incident Number________

← Preliminary Report

← Final Report

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